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A  TREA USE 


ON 


CLINICAL    MEDICINE 


BY 

WILLIAM  HANNA  THOMSON,  M.D.,  LL.D. 

Physician  to  the  Roosevelt  Hospital  ;  Consulting  Physician  to  the  New  York  State  Manhattan  Hospitals 

for  the  Insane,  and  to  the  New  York  Red  Cross  Hospital  ;  formerly  Professor  of  the  Practice  of 

Medicine  and  of  Diseases  of  the  Nervous   System   in    the  New  York  University 

Medical  College;  Ex- President  of  the  New  York  Academy  of  Medicine,  etc. 


PHILADELPHIA  AND  LONDON 

W.    B.   SAUNDERS    COMPANY 

1914 


Published  June,  1914 


Copyright,  IQ14,  W.  B.  Saunders  Company 


Reprinted  December,  1914 


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Cg-n^lm,     \ 


PRINTED     IN    AMERJOA 

PRESS    OF 

W.    B.    SAUNDERS    COMPANY 

PHILADELPHIA 


PREFACE 


A  TREATISE  on  Clinical  Medicine  should  chiefly  consider  those 
subjects  which  concern  the  physician  when  he  deals  with  the  sick. 
Knowledge  gained  in  the  laboratory  or  at  autopsies,  while  indispens- 
able, yet  should  in  time  precede  all  prescribing.  It  is  the  condition 
of  the  living  patient  which  then  demands  exclusive  attention. 

We  begin,  therefore,  with  the  meaning  of  certain  common  but 
always  important  symptoms.  In  each  instance  that  meaning  is 
neither  vague  nor  uncertain,  but  rather  should  be  thoroughly  under- 
stood before  we  go  any  further  in  deahng  with  the  case. 

A  chapter  then  follows  on  the  use  of  remedies  and  how  they  can 
be  most  conveniently  classified  according  to  their  special  appHcations. 

Then  follows  the  section  on  that  greatest  cause  of  disease  and 
death,  namely,  infections  by  living  micro-organisms.  A  good  classi- 
fication of  these  agents  would  be  of  great  service,  and  such  is 
attempted. 

The  last  section  deals  with  diseases  of  particular  organs  and 
tissues. 

Throughout  the  book  the  aim  of  the  author  has  been  to  serve  the 
physician  while  he  is  actively  engaged  in  the  performance  of  his  pro- 
fessional duties. 

William  Hanna  Thomson. 

New  York  City. 

11 


t 

■J) 


CONTENTS 


PART  I 
INTRODUCTION 

PAGE 

Chapter  I. — Mechanism  of  Surface  Chill  or  "  Catching  Cold" 17 

Chapter  II. — Significance  of  Common  but  Important  SvTiiPXOMS 24 

Pain,  24 — Emaciation,  42 — Cough,  51 — Dyspnea,  56 — Edema,  58 — Vomit- 
ing, 61. 

Chapter  III. — Remedies 64 

Non-medicinal,  64 — Medicinal,  68 — Vaccine  and  Serum  Therapy,  70. 

PART  II 

THE   INFECTIONS 

Chapter  I. — General  Introduction  and  Classification 73 

Chapter  II. — Acute  Infections  Directly  Communicable  or  Contagious 80 

Plague  or  Pestis,  80 — Small-pox,  83 — Scarlet  Fever,  87 — Measles,  93 — Rubella, 
96 — ^Typhus  Fever,  96 — Diphtheria,  99 — Whooping-cough,  107 — Mumps,  no — 
Influenza,  in — Chronic  Infections  Directly  Communicable  or  Contagious,  113 — 
Syphilis,  113 — Tabes  Dorsalis,  124 — Parasyphilitic  Affections,  124 — Paresis,  or 
General  Paralysis  of  Insane,  133 — Gonorrhea,  134. 

Chapter  III. — Infections  Commxhsticable  by  Intermediate  Carriers 138 

Lobar  Pneumonia,  138 — ^Typhoid  Fever,  146 — Parat3^hoid  Fever,  161 — 
Meat-poisoning,  161 — Asiatic  Cholera,  161 — Anthrax,  166 — Tuberculosis,  167 — 
Leprosy,  184 — Rheumatic  Fever,  186 — Chorea,  192 — Cerebrospinal  Meningitis, 
195 — Erysipelas,  197 — Pyemia,  202 — Dengue,  202 — Beriberi,  203 — Pellagra, 
204 — Actinomycosis,  206 — Relapsing  Fever,  206 — Malta  Fever,  207. 

Chapter  IV. — Infections  Communicable  by  Inoculation 209 

Malaria,  209 — Yellow  Fever,  218 — ^Tetanus,  221 — Hydrophobia,  225 — 
Sleeping  Sickness,  227 — Kala-azar,  229 — Rocky  Mountain  Fever,  230 — Surgical 
Infections,  231. 

Chapter  V. — Infections  by  the  Bacillus  Colt 232 

PART  III 

DISEASES   OF   SPECIAL   TISSUES   OR  ORGANS 

Chapter  I. — Diseases  of  the  Blood 237 

Chlorosis,  237 — Anemias,  Primary  and  Secondary,  240 — Pernicious  Anemia, 
241 — ^Leukemia,  243 — Hemophilia,  245 — Scurvy,  246 — Infantile  Scurvy,  247— 
Purpura,  247 — Hemoglobinuria,  247 — Cyanosis,  248. 

13 


14  CONTENTS 

PAGE 

Chapter  II. — Diseases  of  the  Circulatory  Apparatus 249 

Examination  of  the  Blood-vessels,  249 — Diseases  of  the  Capillaries,  257 — 
Pulse,  257 — Heart-block  or  Stokes- Adams'  Disease,  259 — Arteriosclerosis,  260 — 
Aneurysm,  267 — Endocarditis,  272 — Malignant  Endocarditis,  276 — Pericardi- 
tis, 278 — Peri-pericarditis,  281 — Bradycardia,  281 — Chronic  Valvular  Disease, 
282 — Aortic  Stenosis,  284 — Aortic  Regurgitation,  285 — Mitral  Stenosis,  287 — 
Mitral  Regurgitation,  288 — Paroxysmal  Tachycardia,  291 — Angina  Pectoris, 
291 — False  or  Neurotic  Angina  Pectoris,  294. 

Chapter  III. — Diseases  of  the  Lymphatics 295 

Hodgkin's  Disease,  295. 

Chapter  IV. — Diseases  of  the  Bones  and  Joints 297 

Chronic  Fibrositis,  or  Chronic  Muscular  Rhevmiatism,  297 — Arthropathies, 
298 — Arthritis  Deformans,  or  Rhetmiatoid  Arthritis,  298 — Osteomalacia,  or 
Fragilitas  Ossium,  301 — Pulmonary  Osteo-arthropathy,  301 — Phosphorus 
Necrosis,  302. 

Chapter  V. — Diseases  of  the  Respiratory  Apparatus 303 

Nose,  304 — Coryza,  304 — Epistaxis,  305 — Asthma,  306 — Hay-fever,  310 — 
Acute  Laryngitis,  312 — Edema  of  Glottis,  313 — Chronic  Laryngitis,  3i3^Tuber- 
cular  Laryngitis,  313 — Laryngismus  Stridiilus,  or  Spasmodic  Croup,  314 — 
Bronchitis,  314 — Fibrinous  Bronchitis,  317 — Bronchopneumonia,  318 — Bron- 
chiectasis, 320 — Gangrene  of  the  Lung,  321 — Pleuritis,  322 — Pneumothorax  and 
Hydropneumothorax,  327 — Cirrhosis  of  the  Lung,  328 — Emphysema,  329 — 
Empyema,  331 — Hiccup,  332. 

Chapter  VI. — Diseases  of  the  Organs  of  Digestion 333 

Stomatitis,  331 — Oral  Sepsis,  335 — Bad  Breath,  336 — Affections  of  the 
Esophagus,  337 — Disorders  of  the  Stomach,  338 — Introduction,  338 — Acute 
Gastritis,  344 — Chronic  Gastritis,  344— Phlegmonous  Gastritis,  346 — Gastro- 
duodenal  Ulcers,  347 — Chronic  Gastroduodenal  Ulcers,  351 — ^Acute  Gastric 
Dilatation,  355 — Chronic  Gastric  Dilatation,  355 — Hyperc];ilorhydria,  357 — 
Achylia  Gastrica,  360 — Achlorhydria  Haemorrhagica  Gastrica,  360 — Foreign 
Bodies,  361 — Intestinal  Disorders,  361 — Diarrhea,  361 — Peritonitis,  364 — 
Ascites,  366 — Intestinal  Motility,  367 — Ileus,  369 — Enteroptosis,  369 — Intes- 
tinal Discharges,  372 — Choleraic  Diarrhea,  374 — Appendicitis,  377 — Mucous 
Colitis,  379— Bacillary  Dysentery,  386— Amebic  Dysentery,  388— Rectal 
Ulcers,  390 — ^Hemorrhoids,  391. 

Chapter  VII. — Diseases  of  the  Liver 392 

Hepatitis,  392— Chronic  Capsulitis  (Perihepatitis),  392— Jaundice,  393— 
Cholelithiasis,  Cholecystitis,  and  Stenosis,  395 — Cirrhosis  of  the  Liver,  406 — 
Alcoholic  Cirrhosis,  406— Fatty  .  Cirrhotic  Liver,  409— Syphilitic  Cirrhosis, 
409— Hypertrophic  Cirrhosis  (Hanot),  411— Pylephlebitis,  412— Abscess  of  the 
Liver,  412— Acute  Yellow  Atrophy,  413— Amyloid  Degeneration,  414— Mov- 
able Liver,  414. 

Chapter  VIII. — Diseases  of  the  Spleen 4i5 

Chapter  IX. — Diseases  of  the  Pancreas 4i6 

Pancreatic  Hemorrhage,  417— Acute  Pancreatitis,  418— Chronic  Pancreatitis, 
419 — Pancreatic  Calculi,  419. 


CONTENTS  15 

PAGE 

Chapter  X. — Diseases  of  the  Urinary  Apparatus 420 

Acute  Nephritis,  420 — Chronic  Nephritis,  423 — Chronic  Interstitial  Nephri- 
tis, 427 — Arteriorenal  Sclerosis,  431 — Uremia,  432 — Nephrolithiasis  (Oxaluria;, 
435 — Cystitis,  437 — Pyelitis,  438 — Hydronephrosis,  440 — rerinephric  Abscess, 
441 — Morbid  Conditions  of  the  Urine,  442 — Indicanuria,  442 — Lithuria,  443 — 
Phosphaturia,  443 — Chyluria,  443 — Cystinuria,  444 — Melanuria,  445 — Bacte- 
rinuria,  445 — Tumors  of  the  Kidney,  445 — Cysts  of  the  Kidney,  445 — Movable 
Kidney,  446. 

Chapter  XI. — Diseases  of  Metabolism 447 

Gout,  447 — Diabetes  Mellitus,  451 — Diabetes  Insipidus,  459 — Rachitis,  or 
Rickets,  460 — Scleroderma,  461 — Obesity,  461 — Fatty  Tumors,  462. 

Chapter  XII. — Diseases  of  the  Ductless  Glands 463 

Introduction,  463 — My.xedema,  464 — Diseases  of  the  Thymus  Gland,  465 — 
Diseases  of  the  Pituitary  Gland,  466 — Acromegaly,  466 — Diseases  of  the  Adre- 
nals, 467 — Addison's  Disease,  467 — Diseases  of  the  Thyroid  Gland,  469— 
Cretinism,  469 — Graves'  Disease,  473. 

Chapter  XIII. — Diseases  Caused  by  Animal  Parasites 494 

Cestodes,  or  Tapeworms,  494 — Hydatids,  or  Echinococci,  496 — Trichiniasis, 
498 — Ascarides,  499 — O.xyuris  Vermicularis  (Pin-worms),  500 — Ankylostomiasis 
(Hookworm  Disease),  500 — Balantidium  Coli,  502 — Dracontiasis  (Guinea- worm 
Disease),  502 — Filariasis,  503 — Other  Nematodes,  503 — Parasitic  Arachnoids, 
504 — Scabies,  504 — Parasitic  Insects,  505 — Affections  from  Caterpillars,  506. 

Chapter  XIV. — Drug  Habits 507 

Chapter  XV. — Mineral  Poisons : 515 

Lead-poisoning,  515 — Arsenic-poisoning,  519. 

Chapter  XVI. — Diseases  of  the  Nervous  System 520 

General  Introduction,  520 — Functional  Nervous  Diseases,  523 — Epilepsy, 
523— Catalepsy,  533 — Infantile  Convvdsions,  533 — Vertigo,  534 — Hysteria,  538 — 
Paralysis  Agitans,  541 — Gastric  and  Other  Neuroses,  544 — Neiorasthenia,  545 — 
Migraine,  549 — Raynaud's  Disease,  553 — Erythromelalgia,  554. 

Chapter  XVII. — Organic  Nervous  Diseases 555 

Lateral  Sclerosis,  555 — Disseminated  Sclerosis,  556 — Amyotrophic  Lateral 
Sclerosis,  559 — Acute  Anterior  Poliomyelitis,  560 — Chronic  Anterior  Polio- 
myelitis, 566 — Chronic  Atrophic  Paralysis,  566 — Progressive  Muscular  Atrophy, 
566 — Bulbar  Paralysis,  568 — Syringomyelia,  569— Affections  of  Brachial  Plexus, 
572 — ^Lesions  of  Individual  Nerves  of  the  Plexus,  573 — ^Affections  of  Lumbar 
Plexus,  575 — Sciatica,  577— Herpes  Zoster,  579— Landry's  Paralysis,  581 — 
Myelitis,  581 — Pott's  Disease,  582 — Neuritis,  583— Angioneurotic  Edema,  584. 

Chapter  XVIIL— Diseases  of  the  Cranial  Nerves 586 

Olfactory  Nerve  and  Tract,  586 — Optic  Nerve  and  Tract,  586 — Albuminuric 
Retinitis,  587— Optic  Neuritis,  588— Optic  Atrophy,  588— Trigeminus  or  Fifth 
Nerve,  589 — Trigeminal  Neuralgia,  590 — Paralysis  of  Facial  Nerve,  593 — Spasm, 
594 — Affections  of  Auditory  Nerve,  594 — Glossopharyngeal  Nerve,  598 — Pneumo- 
gastric  Nerve,  598— Spinal  Accessory  Nerve,  600 — Hypoglossal  Nerve,  601. 

Chapter  XIX. — Diseases  of  the  Cerebral  Arteries 602 

Apoplexy,  602 — Hemiplegia,  606 — Insolation,  or  Simstroke,  610. 


1 6  CONTENTS 

PAGE 

Chapter  XX.— Diseases  of  the  Brain 613 

Introduction,  613 — ^Aphasia,  613 — Encephalitis,  619 — Hydrocephalus,  619 — 
Brain  Tumors,  620 — Abscess  of  the  Brain,  621 — Neuromata,  622. 

Chapter  XXI. — Diseases  of  the  Muscles 623 

Introduction,  623 — Myositis,  623 — Myotonia  or  Thomsen's  Disease,  624 — 
Myasthenia  Gravis,  624— Friedreich's  Disease,  624— Myalgia,  625. 

Chapter  XXII. — Malignant  Diseases 626 

Introduction  to  the  Study  of  New  Growths,  626 — Cancer  of  the  Esophagus, 
631 — Cancer  of  the  Stomach,  631 — Cancer  of  the  Intestinal  Tract,  633 — Cancer 
of  the  Liver,  634 — Cancer  of  the  Breast,  635 — Cancer  of  the  Lung,  635 — Sarcoma, 
636 — Treatment  of  Cancer  and  Sarcoma,  638. 

Index 641 


CLINICAL  MEDICINE 


PART  I 

INTRODUCTION 


CHAPTER     I 


PATHOLOGY    OF    CHILL    AFFECTING    LOCALIZED    AREAS 

OF    THE    SKIN 

Outside  of  hot,  moist  climates,  the  most  common  cause  of  disease 
and  of  death  is  from  "catching  cold."  I  first  drew  attention  to  the 
etiology  and  mechanism  of  this  derangement  in  my  inaugural  as  presi- 
dent of  the  New  York  Academy  of  Medicine  in  1899.  Yet  it  should 
be  clearly  understood  that  this  disorder,  however  local,  is  always 
caused  by  an  interference  with  the  supply  of  arterial,  and  not  of 
venous,  blood  to  the  part.  This  fact  was  plainly  illustrated  by  the 
experiment  of  Overbach,  who  found  that  clamping  the  renal  arteries 
for  only  forty  minutes,  so  as  to  obstruct  the  flow  of  blood  through  the 
kidneys,  was  followed  by  albuminous  urine  for  twenty  days.  We  may 
conclude,  therefore,  that  any  local  shutting  off  of  arterial  blood  will 
promptly  induce  nutritive  changes  in  the  territory  of  that  arterial 
distribution,  which  are  at  least  analogous  to  the  local  inflammatory 
changes  which  we  trace  to  "catching  cold." 

Now  the  arterial  flow,  in  distinction  generally  from  the  venous, 
is  under  the  regulation  of  a  special  department  of  the  nervous  system, 
called  the  vasomotor  nerves.  This  is  well  shown  in  the  circulation 
of  organs  which  are  in  symmetric  pairs,  such  as  the  two  eyes,  the  two 
ears,  the  two  hands,  and  the  two  feet,  but  this  association  does  not 
obtain  in  the  pair-organs  which  are  not  symmetric,  such  as  the  two 
lungs  and  the  two  kidneys.  As  to  the  symmetric  organs,  if  thermome- 
ters be  placed  in  the  axillae,  and  then  one  thermometer  be  held  in  the 
left  hand  while  the  right  hand  is  plunged  in  ice-water,  the  thermometer 
2  17 


1 8  CLINICAL   MEDICINE 

in  that  hand  will  fall  2°  to  5°  F.  from  arterial  contraction  in  it,  while 
those  in  the  axillas  are  unaffected.  If  the  semitranslucent  ears  of  a 
rabbit  are  held  up  to  the  hght  the  readily  seen  pulsation  of  the  arteries 
in  one  ear  is  found  to  cease  at  once  when  the  other  ear  is  pinched. 
Now,  Overbach's  experiment  shows  that  the  integrity  of  the  tissues 
of  a  most  important  organ  can  be  seriously  deranged  by  only  a  very 
temporary  withdrawal  of  arterial  blood. 

In  the  firstplace,  it  is  evident  that  "catching  cold"  is  a  very  different 
thing  from  being  chilled  by  cold;  that  is,  from  a  general  cooling  of 
the  body;  for  its  most  typical,  as  well  as  disastrous,  results  may  occur 
while  a  person  sits  with  his  entire  body  wrapped  carefully  in  winter 
clothes,  but  the  feet  meantime  soaked,  because  he  went  out  without 
his  rubbers  into  melting  snow.  A  cold  draft  on  the  back  of  the 
neck,  however  induced,  may,  according  to  individual  susceptibiHty, 
cause  a  rhinitis,  a  pharyngitis,  a  laryngitis,  a  bronchitis,  a  pneumonia, 
or  a  pleuritis.  How  do  such  purely  local  impressions  of  cold  occasion 
such  widely  distributed  organic  mischief?  As  we  have  remarked, 
we  must  look  to  the  nervous  system  for  our  chief  explanations.  One 
of  the  first  clews  toward  the  solution  of  this  problem  was  furnished 
by  an  observation  of  Cohnheim,  that,  after  long-continued  anemia  of 
the  rabbit's  ear  by  ligature,  the  blood-vessels  became  so  permeable 
that  the  restoration  of  the  normal  circulation  was  followed  by  pro- 
nounced edema  of  all  the  tissues  and  degenerative  changes  in  their 
cells. 

The  principle,  therefore,  which  we  would  elucidate  here  is  that  the 
integrity  of  the  tissues  of  the  body  depends  upon  the  constant  circula- 
tion through  them  of  arterial,  and  not  of  venous,  blood.  Whatever 
interferes  with  the  circulation  of  arterial  blood,  though  it  be  but  a 
short  interference,  nevertheless  produces  serious  damage  to  the  tissues. 
Guided  by  this  principle,  we  can  understand  what  "catching  cold" 
means,  because  every  organ  of  the  body,  particularly  if  it  be  very 
vascular,  is  sensitive  to  the  withdrawal  or  interference  with  its  arterial 
circulation,  and  hence  this  leads  us  to  inquire  into  the  special  mechan- 
ism of  the  arteries  as  they  are  governed  by  their  vasomotor  nerves. 

The  vasomotor  nerves  are  but  rarely  acted  upon  by  a  general  stim- 
ulus. Instead,  vasomotor  stimuli  are  definitely  local,  and  yet  subject 
to  certain  special  laws.  A  study  of  these  laws  will  throw  much  Ught 
upon  our  subject  of  "catching  cold."  Thus,  as  we  have  seen,  the 
first  law  is  illustrated  by  the  intimate  association  of  the  vasomotor 
nerves  supplying  symmetric  organs  in  pairs.  In  the  case  of  the 
hands  I  once  made  use  of  this  property  in  a  boy  who  had  a  pistol  shot 


PATHOLOGY  OF  CHILL  AFFECTING  LOCALIZED  AREAS  OF  SKIN   1 9 

perforate  the  palm  of  his  hand  so  as  to  sever  the  pahnar  arterial  arch. 
This  necessitated  both  the  cut  ends  being  Ugated,  but  the  hemorrhage 
was  so  troublesome  that  I  could  not  secure  the  vessels  until  his  other 
hand  had  been  dipped  in  ice-water,  whereupon  the  bleeding  was 
checked  enough  for  me  to  find  and  tie  the  vessels  without  difficulty. 

A  second  law  is  the  intimate  association  between  the  vasomotor 
nerves  of  any  area  of  the  skin  and  those  of  the  internal  parts  under- 
neath that  area.  This  is  an  important  law,  as  it  affords  the  explana- 
tion of  a  great  many  chnical  facts.  Thus,  external  applications,  accord- 
ing to  their  nature,  can  produce  marked  stimulative  or  else  sedative 
impressions  upon  the  circulation  of  the  parts  underneath  that  area. 
This  explains  why  poultices  may  so  reheve  pain  and  inflammatory 
irritation  when  appUed  to  the  skin ;  but  Hkewise  we  find  this  law  opera- 
tive where  it  is  important  to  stimulate  the  circulation  in  the  stage  of 
venous  stasis. 

Thus,  after  the  subsidence  of  the  acute  stage  of  inflammation,  we 
have  a  powerful  stimulant  to  the  internal  circulation  by  dry  cupping, 
which  is  especially  useful  in  the  bronchitis  of  adults.  Likewise  the 
appHcation  of  a  bhster  is  actively  stimulant  to  the  internal  circula- 
tion, but  should  not  be  apphed  in  the  first  stage  of  the  inflammation. 

These  considerations  lead  directly  to  the  whole  subject  of  counter- 
irritation.  Thus,  the  effect  of  local  bloodletting  is  always  sedative. 
I  have  relieved  the  agonizing  paroxysms  of  dyspnea  from  a  thoracic 
aneurysm  by  a  single  leech  applied  at  the  notch  of  the  sternum.  A 
further  illustration  of  this  law  is  found  in  the  saving  of  Hfe  from  a 
quickly  fatal  postpartum  hemorrhage  by  dashing  cold  water  upon  the 
abdomen  or,  better  yet,  by  the  sudden,  intense  cold  of  the  ether  spray. 
Of  course,  this  arrest  of  the  hemorrhage  is  not  due  to  the  general  cool- 
ing of  the  parts  involved,  but  acts  only  through  reflex  vasomotor  as- 
sociation. 

But  this  law  has  also  an  obverse  application  of  much  practical 
importance.  Every  internal  inflammation  causes  a  marked  hyperes- 
thesia of  the  skin  over  the  inflamed  organ,  which  leads  to  any  irrita- 
tion of  it  being  reflected  inward  to  the  aggravation  of  the  inflammation. 
I  once  saw  a  distinguished  clinician  expose  the  chest  of  a  woman  with 
pericarditis  for  nearly  an  hour,  so  that  each  of  his  students  might  suc- 
cessively hsten  to  the  pericardial  rub.  The  result  was  that  in  a  very 
few  hours  the  patient's  life  was  despaired  of  from  a  spread  of  the  in- 
flammation to  the  whole  pericardium. 

Another  important  law  is,  that  through  the  vasomotor  system 
special  associations    occur   between   certain  widely  separated  parts 


20  CLINICAL  MEDICINE 

of  the  body.  All  vasomotor  nerves  are  particularly  susceptible  to 
the  irritant  impression  of  cold.  This  is  illustrated  in  the  case  of  the 
association  existing  between  the  feet  and  the  circulation  of  the  pelvic 
viscera.  So  girls  can  have  recourse  to  a  very  dangerous  suppression 
of  the  menses  by  putting  their  feet  into  cold  water.  It  is  surprising 
how  long  this  injurious  impression  is  retained  by  the  pelvic  nerves,  so 
as  to  cause  long-continued  amenorrhea.  On  the  other  hand,  I  have 
found  no  agent  so  effective  in  restoring  the  function  of  menstruation 
as  that  of  dry  (not  moist)  heat,  appHed  for  prolonged  periods  to  the 
feet.  Likewise,  no  patient  with  an  irritable  stricture  of  the  urethra 
should  allow  his  feet  to  get  wet  and  cold,  and  the  same  may  be  said  of 
cases  of  cystitis.  Also  due  to  the  same  vasomotor  association,  if 
profuse  bleeding  occurs  during  operations  about  the  rectum,  the 
hemorrhage  may  be  largely  controlled  by  immersing  the  feet  in  cold 
water. 

But  the  vasomotor  nerves  of  the  feet  form  another  association 
which  is  of  much  importance,  and  that  is  with  the  circulation  of  the 
pharynx  and  the  larynx.  Everyone  knows  that  getting  the  feet  wet 
may  quickly  produce  a  sore  throat,  if  not  an  attack  of  hoarseness, 
extending  finally  into  bronchitis. 

Still  another  important  association  is  between  the  nerves  arising 
at  the  nape  of  the  neck  and  the  whole  arterial  circulation  of  the 
head  and  face;  in  fact,  we  may  say  that  at  the  nape  of  the  neck  is  the 
chief  executive  office  which  presides  over  the  whole  circulation  above 
the  diaphragm,  including,  of  course,  the  circulation  of  the  mucous 
membranes.  One  domestic  remedy,  for  example,  was  to  check  nose- 
bleed in  a  child  by  sHpping  a  cold  key  down  the  back  of  its  neck. 
How  local  the  primary  excitation  may  be  is  shown  by  the  results  of 
exposing  the  back  of  the  neck  to  a  cold  draft  of  air.  The  most 
extensive  inflammation  of  mucous  membranes  may  result  from  a  pro- 
longed exposure,  though  the  rest  of  the  body  may  be  warmly  clad. 
Nasal  catarrh  or,  in  fact,  catarrh  of  the  whole  respiratory  tract  may 
soon  follow  from  thus  "catching  cold." 

But  a  fact  of  the  highest  moment  connected  with  "catching  cold"  is, 
that  by  the  local  damage  to  an  internal  part  the  way  is  opened  for 
infecting  micro-organisms  of  the  most  varied  kind  to  enter  the  system. 
Many  of  these  infecting  agents  may  be  found  throughout  hfe  occupy- 
ing the  mouth  and  throat,  but  doing  no  harm  so  long  as  the  epithelium 
lining  of  the  mucous  membrane  is  intact;  such  is  the  case  with  the  pneu- 
mococcus  and  a  whole  host  of  similar  and  powerful  infecting  agents. 
The  demonstrated  seasonal  relationships  of  pneumonia  show  this  very 


PATHOLOGY    OF    CHILL    AFFECTING   LOCALIZED    AREAS    OF   SKIN      21 

clearly.  These  infecting  micro-organisms  are  as  little  able  to  pene- 
trate a  healthy  mucous  surface  as  the  streptococci  and  staphylococci, 
which  always  swarm  on  the  skin,  but  can  do  no  mischief  until  the 
surgeon  ventures  to  make  an  incision  in  it. 

These  vasomotor  associations  have  their  widest  illustrations  in  the 
causation  and  course  of  bronchitis.  Sometimes  getting  the  feet  wet 
begins,  as  we  have  explained,  a  cold  which  first  makes  the  voice 
hoarse,  and  then,  from  the  larynx,  proceeds  steadily  down  the  trachea 
and  larger  bronchi  until  the  smaller  air-tubes  become  involved. 
Oftener  than  that,  however,  the  vasomotor  centers  at  the  nape  of  the 
neck  set  up  a  catarrhal  inflammation  of  the  nasal  passages,  and  then, 
with  this  derangement  in  the  beginning  of  the  breathing  apparatus, 
it  progressively  invades  the  whole  respiratory  tract.  Yet  just  this 
sequence  occurs  also  when  this  tract  is  directly  invaded  by  the  specific . 
infections  of  influenza,  measles,  and  whooping-cough.  But  what  we 
particularly  wish  to  explain  here  is  the  mechanism  of  the  many  fatal 
complications  of  bronchitis. 

We  begin  with  the  disasters  which  follow  upon  the  plugging  of  a 
main  bronchus  by  the  accidental  lodgment  in  it  of  a  foreign  body. 
If  this  be  not  removed,  death  inevitably  ensues  from  a  most  disorgan- 
izing pneumonic  process  of  the  part  supphed  by  the  bronchus,  in  which 
not  only  are  all  the  air-vesicles  wholly  destroyed,  which  they  are  not 
in  croupous  pneumonia,  but  the  interlobular  as  well  as  the  inter- 
vesicular  connective  framework  is  rapidly  damaged.  No  ruin  of 
pulmonary  tissues  compares  with  this  for  completeness. 

Now,  it  should  be  borne  in  mind  that  both  the  larger  and  the  smaller 
bronchi  should  never  contain  anything  but  air.  Their  walls  are 
simply  moistened  by  a  bland,  shghtly  saline  fluid,  and  in  no  part  of 
the  body  is  the  sa3dng  more  true  that  no  mucous  membrane  should 
ever  secrete  mucus.  When,  instead,  its  surface  is  coated  with  mucus, 
it  is  already  in  a  morbid  condition,  denoting  inflammation.  In  the 
bronchi  this  is  doubly  true,  for  secretions  there,  no  matter  how  fluid, 
are,  to  all  intents  and  purposes,  foreign  bodies,  and  must  be  got  rid  of. 
If  they  cannot  be  got  rid  of,  the  part  supphed  by  that  bronchus  is 
subject  to  the  same  disorganization  as  that  described  following  the 
plugging  of  a  main  bronchus.  It  is  then  that  we  have  a  locahzed-, 
but  ruinous  bronchopneumonia,  however  small  its  area  may  be. 

Bronchopneumonia,  therefore,  occurs  in  every  disease  accompanied 
by  bronchitis  whenever,  as  in  children,  the  powers  of  expectoration 
are  feeble,  particularly  in  measles  and  whooping-cough,  and  is  the 
most  common  cause  of  death  in  all  such  affections.     But  its  initial 


22  CLINICAL  MEDICINE 

mechanical  cause  should  not  be  lost  sight  of,  the  practical  aim  always 
being  to  make  the  secretions  so  fluid  that  they  can  easily  be  coughed 
away.  In  adults  this  is  usually  accomplished  with  ease.  If  the 
secretion,  however,  is  very  viscid,  the  coughing  is  hard,  and  in  chronic 
cases  leads  to  emphysematous  overdistention,  if  not  rupture,  of  the 
air-vesicles.  In  infants,  as  already  explained,  the  immediate  results 
are  very  serious.  The  small  occluded  bronchi  now  lead  to  the  same 
disorganizing  process  in  the  httle  lobules  supplied  by  the  bronchus, 
which  occurs  as  the  result  above  described  accompanying  occlusion  of 
a  main  bronchus.  Scattered  pneumonic  processes  are,  therefore, 
found  through  both  lungs,  for  bronchitis,  unlike  croupous  pneumonia, 
is  a  bilateral  affection.  In  some  cases,  however,  the  plug  in  a  small 
bronchus  may  act  as  a  valve,  interfering  with  the  inspiration  but 
not  with  the  expiration,  thus  leading  to  atelectasis  of  the  lobule,  so 
that  in  bronchopneumonia  we  find  both  pneumonic  consohdation  of 
lobules  along  with  collapsed  lobules,  either  condition,  of  course,  equally 
interfering  with  the  breathing.  In  infants,  therefore,  this  whole  proc- 
ess leads  to  most  distressing  efforts  to  get  air.  The  httle  patients  toss 
from  side  to  side  in  their  vain  endeavors  to  breathe,  until  signs  of 
carbonic-acid-poisoning  show  the  last  effects  of  gradual  suffocation; 
but  we  meet  with  practically  the  same  conditions  in  aged  patients 
from  their  feeble  powers  to  expectorate.  Remembering,  however,  the 
purely  mechanical  operation  of  their  respiratory  obstruction,  I 
once  had  an  old  lady,  eighty-four  years  old,  mother  of  a  prominent 
New  York  judge,  raised  feet  upward  by  her  nurses,  while  her  head 
touched  the  floor,  and  while  in  this  position  assisted  her  expectoration 
by  pressure  on  the  sides  of  the  thorax  during  expiration.  She  thus 
got  rid  of  large  quantities  of  mucus,  and  was  soon  restored  to  bed  quite 
comfortable,  ultimately  recovering. 

In  no  disorder  of  the  lungs  does  this  morbid  condition  so  facilitate 
infection  by  every  variety  of  micro-organism,  including  tuberculosis, 
a  not  uncommon  sequel,  especially  after  measles. 

Treatment. — The  various  conditions  above  described  afford  many 
indications  for  treatment.  Thus,  chronic  nasal  catarrhs  point  to  a 
weakened  susceptibility  of  the  vasomotor  centers  at  the  nape  of  the 
neck.  Nothing  so  restores  the  tone  of  these  weakened  centers  as 
cold  properly  appHed.  Thus,  a  cold  bath  or  shower-bath  invigorates 
the  circulation,  provided  always  that  the  reaction  from  the  impres- 
sion of  cold  is  complete,  but  if  not,  or  equally  imperfect  reaction 
occurs,  the  patient  is  worse  off  than  ever;  hence,  chronic  nasal  catarrhs 
are  best  treated  by  sudden  and  very  brief  douching  of  the  back  of  the 


PATHOLOGY    OF    CHILL    AFFECTING    LOCALIZED    AREAS    OF    SKIN      23 

neck  with  cold  water,  to  be  followed  by  active  dry  friction,  to  assist 
or  to  promote  the  restoration  of  the  circulation  in  the  parts.  During 
the  douche  the  hair  should  be  carefully  protected  from  the  water,  for 
wet  hair  would  only  prolong  the  injurious  effect  of  chill.  Meanwhile 
the  nose  itself  may  be  treated  with  insufiflation  of  a  fine  powder,  com- 
posed of  2  drams  of  subcarbonate  of  bismuth  with  6  gr.  of  aristol. 

Bearing  in  mind  what  we  have  said  about  internal  inflammation 
causing  hyperesthesia  or  great  sensitiveness  of  the  corresponding  area 
of  skin  over  the  seat  of  the  inflammation,  any  area  of  chronic  inflam- 
mation should  have  the  corresponding  cutaneous  surface  carefully 
protected.  In  health,  if  a  cold  hand  be  placed  suddenly  over  the  pre- 
cordium,  the  heart  will  give  a  bound,  but  so  all  cases  of  heart  trouble, 
whether  the  result  of  pericarditis  or  endocarditis,  are  very  sensitive 
to  surface  impressions  which  would  not  normally  be  felt.  This  ex- 
plains the  beneficial  results  following  apphcations  of  large  belladonna 
plasters,  which  should  cover  the  whole  area  of  the  skin  over  the  heart, 
but  these  facts  are  equally  appKcable  in  all  chronic  inflammatory 
conditions,  whether  of  the  lungs  or  of  the  pleura.  Chest  protectors, 
on  that  account,  are  reasonable.  I  prefer  the  application  of  cotton 
batting  to  any  other  such  measure.  Similarly,  every  patient  mth 
chronic  diarrhea  should  have  his  abdomen  covered  by  some  equivalent 
protection.  In  chronic,  long-standing  bronchitis  I  have  the  patients 
wear  both  shirts  and  drawers  made  with  perforated  chamois  skin,  worn 
just  over  a  light  undergarment.  I  have  often  been  told  by  such  patients 
that  they  could  spend  their  winters  at  home,  when  before  they  used 
these  protections  to  the  skin  they  were  unable  to  do  so.  Osier  says,  in 
his  "Practice  of  Medicine,"  "Thus,  in  the  convalescence  from  measles 
and  whooping-cough  it  is  very  important  that  the  child  should  not 
be  exposed  to  the  cold,  particularly  at  night,  when  the  temperature  of 
the  room  naturally  falls.  In  a  nocturnal  visit  to  the  nursery — some- 
times, too,  I  am  sorry  to  say,  to  a  children's  hospital — how  often  one 
sees  children  almost  naked,  having  kicked  aside  the  bedclothes  and 
having  the  night-clothes  up  about  the  arms." 

In  my  practice  I  have  all  such  children,  while  tossing  about  strug- 
gling for  breath,  and  thus  exposing  themselves,  put  into  bags  of  canton 
flannel,  drawn  about  the  neck,  so  as  to  prevent  them  from  exposing 
the  skin  to  the  cold  air. 


CHAPTER    II 

SIGNIFICANCE  OF  SOME  IMPORTANT  SYMPTOMS 

The  first  duty  of  a  physician  is  to  recognize  the  actual  condition 
of  his  patient.  This  may  involve  more  than  the  diagnosis  of  any  spe- 
cial malady  which  he  may  have,  because  the  accompanying  conditions 
vary  indefinitely  in  different  persons  whatever  the  name  of  the  dis- 
ease. It  may  be  the  accompanying  conditions  which  chiefly  deter- 
mine the  nature  of  the  prognosis,  whether  it  be  favorable  or  unfavor- 
able, along  with  the  leading  indications  for  treatment.  In  other 
words,  the  more  comprehensive  the  diagnosis  be,  the  better. 

On  this  account  certain  common  but  important  symptoms  of  dis- 
ease assume  an  interest  quite  their  own,  sufficient  to  warrant  their 
being  made  the  subjects  of  separate  study.  Each  of  these  sjonptoms 
when  present  constitutes  in  itself  practical  information  about  the 
patient  worthy  of  the  completest  investigation  until  all  its  possible 
bearings  are  determined.  Not  infrequently  such  consideration  leads 
to  conclusions  of  as  great  clinical  importance  as  any  questions  about 
pathology  or  etiology,  besides  suggesting  many  a  clue  to  correct  diag- 
nosis. 

THE  SIGNIFICANCE  OF  PAIN 

We  begin  with  the  subject  of  pain  as  a  good  illustration  of  the 
advantage  which  the  particular  study  of  a  single  symptom  may  afford. 
In  diagnostic  value  alone  it  is  not  to  be  surpassed  by  any  of  the  com- 
mon s5rmptoms  of  disease,  enough  to  warrant,  whenever  pain  is  men- 
tioned by  a  patient,  the  postponement  of  all  other  questions  until 
both  its  nature  and  its  significance  are  clearly  recognized. 

The  investigation  should  begin  with  a  request  that  the  patient 
show  just  where  the  pain  is  felt  most,  and  where  it  first  began.  While 
he  is  doing  so,  the  gestures  which  he  uses  should  be  carefully  noted, 
as  they  often  afford  truer  indications  than  his  language  does,  because 
verbal  descriptions  of  pain  may  be  extremely  indefinite.  As  a  rule, 
such  gestures  are  characteristic  enough  to  aid  materially  in  the  recog- 
nition of  the  particular  variety  of  pain,  if  not  also  of  the  nature  of  the 
affection  itself  which  is  present,  as  the  following  examples  will  show. 

When  the  pain  is  due  to  inflammation,  if  external,  as  with  a  joint, 
24 


THE   SIGNIFICANCE    OF   PAIN  25 

the  patient  will  avoid  touching  the  most  painful  part,  or  he  approaches 
it  in  a  very  respectful  way.  Thus,  with  an  arthritis  his  hand  passes 
over  the  joint  in  a  hovering  fashion.  If  deeper  seated,  the  gestures 
are  often  expressive  of  the  varying  kinds  and  distribution  of  the  pain, 
according  to  the  texture  inflamed.  Thus,  the  diffused  soreness  of  a 
mucous-membrane  inflammation  causes  the  gesture  of  bronchitis  to 
be  made  with  the  whole  hand  laid  on  the  sternum,  and  then  passed 
over  and  across  the  chest.  A  similar  movement  of  the  hand  across 
the  abdomen  never  means  a  peritonitis,  but  a  catarrhal  intestinal 
inflammation.  With  pleurisy,  on  the  other  hand,  the  tips  of  the 
straightened  fingers  are  used  to  indicate  the  stabbing  nature  of  the 
pain.  In  peritonitis,  also,  the  tips  of  the  fingers  are  used,  but  brought 
down  with  more  caution  than  in  pleurisy.  In  the  localized  pain  of 
commencing  appendicitis,  the  open  hand  is  used,  as  with  an  inflamed 
joint.  In  pleurodynia,  the  whole  hand  is  pressed  firmly  to  the  side, 
to  prevent  movement  of  the  ribs.  In  rheumatic  fever,  the  pointing 
by  the  patient  to  the  epigastrium  or  to  the  xiphoid  cartilage,  especi- 
ally if  followed  by  a  movement  from  the  precordium  upward  or  into 
the  left  arm,  is  significant  of  cardiac  inflammation.  So  also  the 
gesture  in  gastritis,  whether  acute  or  chronic,  is  wholly  different  from 
that  in  colic.  Inflammatory  pains  about  the  head  may  have  very 
characteristic  gestures.  The  use  of  one  finger-tip  to  localize  it  on  the 
scalp  is  strongly  significant  of  intracranial  syphihs.  The  finger- 
tips passing  up  the  side  of  the  face  and  stopping  on  the  scalp  an  inch 
below  the  sagittal  suture  indicates  a  pain  ascending  from  a  tooth, 
and  should  not  be  mistaken  for  a  trigeminal  neuralgia.  In  con- 
junctivitis, the  hand  is  laid  over  the  eye.  In  iritis,  the  finger  is  pointed 
toward  it,  not  touching  it,  and  then  passed  up  the  forehead  to  the  in- 
ner side  of  the  nose  or  to  the  malar  process.  In  glaucoma,  the  gesture 
may  be  reversed,  as  if  the  pain  were  emerging  from  the  orbit.  All  these 
gestures  differ  entirely  from  those  of  head-pains  not  inflammatory. 
Meningitis,  whether  cerebral  or  spinal,  is  significantly  indicated  by 
absence  or  suppression  of  gesture,  for  reasons  to  be  noted  further  on. 
The  exceptions  to  this  are  in  some  cases  of  tubercular  meningitis.  But 
the  gesture  of  myelitis,  with  both  hands  passed  from  the  back  across 
the  abdomen,  to  describe  the  cord  or  band-like  sense  of  constriction, 
is  almost  itself  pathognomonic. 

On  the  other  hand,  the  gestures  indicating  the  seat  of  the  greatest 
pain  produced  by  pressure,  as  by  tumors,  abscesses,  etc.,  or  cramps, 
markedly  contrast  with  those  of  inflammatory  pains  in  showing  no 
apprehension  in  touching  or  moving  the  part.     Here  the  locality  in- 


26  CLINICAL  MEDICINE 

dicated  at  first  by  the  gesture  is  of  importance  to  note,  and  whether, 
on  repeating  the  question,  the  same  place  is  again  started  from,  because 
the  patient's  hand  then  moves  in  a  fashion  expressive  of  the  exten- 
sion or  radiation  of  the  pain  from  the  original  focus,  although  he  may 
describe  the  pain  as  equally  present  at  some  distance  from  the  spot 
first  pointed  out.  Hence,  his  unconsciously  repeating  the  sign  with 
which  he  commenced  is  of  much  significance.  Thus,  a  patient  with 
a  growth  springing  from  the  lumbar  vertebrae  always  first  pressed 
the  point  of  two  fingers  deeply  into  the  abdomen  below  the  umbilicus, 
while  the  fingers  of  the  other  hand  moved  over  the  sacrum,  where  he 
insisted  that  his  pain  chiefly  was.  A  fixed  pain  in  the  back,  caused  by 
an  aneurysm,  is  often  indicated  by  the  extended  thumb,  and  like- 
wise the  pain  preceding  herpes  zoster;  but  no  spinal  inflammatory 
pain  will  elicit  such  a  gesture,  nor  will  the  pains  of  so-called  spinal 
irritation. 

In  stretching  pains,  such  as  in  biliary  or  renal  colic  or  cramps,  as  in 
lead-coKc,  the  contrast  to  inflammatory  pains  is  shown  by  the  forcible 
grasp  or  pressure  which  the  patient  makes  on  the  abdomen,  while  the 
characteristic  radiations  of  the  different  varieties  may  be  very  plainly 
represented.  Even  when  the  pain  has  ceased,  the  gestures  descriptive 
of  what  he  had  experienced  may  be  equally  conclusive  as  to  their 
nature. 

The  gestures  expressive  of  simple  neuralgic  pains  contrast  through- 
out with  those  of  inflammatory  pains.  A  functional  occipital  headache 
is  shown  by  a  friction-like  movement  of  the  hand  from  the  neck  up, 
sometimes  followed  by  pressure  on  the  eyes  with  the  fingers.  So 
the  hands  are  used  with  the  firmest  pressure  in  temporal  or  frontal 
neuralgias,  or  the  patient  may  tightly  tie  a  handkerchief  around  the 
head.  This  proneness  to  grasp  or  to  press  as  well  as  to  move  the  ach- 
ing part  is  characteristic  of  neuralgic  pains  everywhere  in  the  body. 
The  gestures  are  also  valuable  from  their  indicating  the  shifting 
character  of  neuralgic  pains,  enough,  at  least,  to  distinguish  them  from 
the  more  fixed  pressure-pains  of  tumors.  Special  characters  of  neu- 
ralgic pains  are  frequently  described  by  the  gestures^  as  in  the  darting 
pains  of  tabes. 

Subjective  pains,  as  in  hysteria,  are  very  characteristic,  in  their 
being  more  numerous  and  varied  than  true  objective  pains  can  be,  and, 
secondly,  in  the  inconsistency  of  the  gestures  with  the  often  highly 
wrought  description  of  them  by  the  patient.  Both  the  language 
and  the  manner  of  the  patient  is  more  like  one  telHng  the  tale  of  a 
woeful  past  experience  than  of  a  present  reaHty. 


THE    SIGNIFICANCE    OF    PAIN  27 

I  might  multiply  many  illustrations  of  the  clinical  value  of  gestures 
descriptive  of  pain  toward  making  a  right  beginning  in  diagnosis.  I 
have  already  impHed,  however,  that  pains  differ  much  in  kind  and 
in  character,  and  hence  the  necessity  of  distinguishing  their  special 
varieties.  For  this  purpose  I  would  classify  them  into  six  different 
forms,  as  follows: 

(i)  Pains  due  to  inflammation;  (2)  pains  due  to  pressure;  (3)  pains 
due  to  stretching;  (4)  neuralgic  pains;  (5)  subjective  pains;  (6)  cuta- 
neous reflex  pains. 

Inflammatory  pains  have  three  great  characteristics.  The  first  is, 
that  pain  is  elicited  by  pressure  upon,  or  by  handling,  the  inflamed 
part,  and  the  rule  is  that  pressure  produces  the  maximum  amount 
of  pain  at  the  seat  of  the  inflammation.  This  fact  is  useful  in  diag- 
nosis, both  positively  and  negatively. 

Thus,  an  inflammatory  pain  in  the  leg  may  be  due  to  peripheral 
neuritis,  to  sciatica,  to  hip-joint  disease,  to  gouty  arthritis,  to  rheu- 
matic arthritis,  to  muscular  rheumatism,  or  to  spinal  meningitis,  and 
each  one  of  these  may  be  distinguished  from  the  others  by  appropri- 
ate palpation.  In  peripheral  neuritis,  pain  is  most  complained  of  on 
pressure  upon  the  skin  and  superficial  structures  much  more  than  when 
you  lift  the  whole  limb  in  your  hands  or  move  its  joints.  Sciatica  is 
diagnosed  by  the  special  tenderness  on  pressure  at  the  sciatic  notch, 
along  the  course  of  the  nerve  down  the  back  of  the  thigh,  or  deep  in 
the  popliteal  space,  or  between  the  heads  of  the  soleus  in  the  calf; 
hip- joint  disease,  by  pressing  the  head  of  the  bone  against  the  acetabu- 
lum. I  have  shown^  that  a  gouty  arthritis  may  be  distinguished  from 
a  rheumatic  arthritis  by  the  different  points  of  tenderness  about  most 
of  the  joints  in  these  two  diseases.  In  gout  the  tenderness  is  distinctly 
most  pronounced  at  the  condyles;  in  rheumatism,  along  the  tendons 
and  at  their  insertions,  and  not  on  the  condyles.  Thus,  at  the  knees, 
in  acute  gout,  the  condyles  are  very  painful  on  pressure  compared  with 
the  rest  of  the  joint,  while  in  rheumatism  the  pain  is  usually  most 
ehcited  by  pressure  on  the  tendon  of  the  quadriceps  above  and  below 
the  patella  and  on  the  tendons  of  the  hamstring  muscles.  This  same 
difference  between  these  two  affections  in  the  points  of  tenderness  is 
also  well  shown  in  the  fingers.  The  pain  of  muscular  rheumatism  in 
the  leg  is  shown  by  pressure  or  manipulation  of  the  muscles  them- 
selves, and  this  serves  to  distinguish  it  from  pains  in  the.  leg  in  spinal 
meningitis,  where  you  may  manipulate  the  muscles  without  pain,  but 
you  cannot  move  the  whole  leg  without  making  the  patient  cry  out 

^  Transactions  of  the  Association  of  American  Physicians,  Washington,  1896. 


28  CLINICAL   MEDICINE 

or,  if  comatose,  groan  from  the  pain  so  caused.  On  the  other  hand, 
a  child  may  complain  of  severe  pain  on  the  inner  aspect  of  the  knee, 
but  you  press  the  part  and  it  does  not  increase  the  pain,  which  shows 
that  the  seat  of  the  inflammation  is  not  there,  but  by  proper  manipu- 
lation may  be  found  higher  up — at  the  hip-joint.  Similarly,  a  child 
may  complain  of  constant  pain  in  the  stomach,  and  I  have  known  such 
a  case  thoroughly  dosed  for  worms,  but  tenderness  on  pressure  at  the 
eighth  dorsal  vertebra  showed  that  it  had  incipient  Pott's  disease. 

Careful  manipulation  to  locate  tenderness  will  frequently  reveal 
the  nature  of  a  trouble  which  otherwise  may  be  obscure.  Tender- 
ness on  pressure  along  the  course  of  an  intercostal  nerve  may  dis- 
pose of  a  diagnosis  of  heart  disease  or,  as  I  have  twice  known,  of  can- 
cer of  the  liver. 

So  tenderness  on  pressure,  rightly  located,  may  indicate  the 
presence  of  a  hepatic  or  of  a  renal  calculus.  In  the  former  case,  if 
the  calculus  is  in  the  cystic  duct,  most  pain  is  elicited  by  pressing  the 
tip  of  the  index-finger  deeply  down  at  a  spot  i|  inches  to  the  right, 
and  a  little  below  the  umbilical  line;  if  it  be  in  the  common  duct, 
the  pain  is  most  pronounced  on  pressure  at  the  base  of  the  right  arch 
of  the  ribs.  In  renal  calculus,  standing  behind  the  patient,  first 
place  the  thumbs  of  both  hands  under  the  last  ribs,  and  then  so  spread 
the  fingers  over  the  abdomen  that  when  the  patient  relaxes  the  ab- 
dominal walls  by  bending  well  down  you  can  push  the  kidneys  up 
toward  the  spine;  then,  as  he  straightens  up,  press  the  thumbs  in 
strongly,  whereupon,  if  he  has  a  renal  calculus,  he  will  quickly  bend 
over  on  that  side.  You  may  further  confirm  the  diagnosis  of  a  hepatic 
or  renal  calculus  by  putting  one  pole  of  a  faradic  battery  on  the  spine, 
and  then  suddenly  applying  the  other  with  firm  pressure  at  the 
places  just  indicated,  when  you  will  distinctly  elicit  the  same  kind 
of  pain  which  manipulation  does.  In  appendicitis,  mucji  is  made  of 
the  special  tenderness  elicited  by  pressure  at  what  is  called  McBurney's 
point,  on  a  line  midway  between  the  anterior  spine  of  the  ileum  and 
the  umbiHcus. 

The  second  great  characteristic  of  inflammatory  pain  is  that  it  is 
increased  by  any  form  of  movement  of  the  inflamed  part,  not  except- 
ing its  own  proper  functional  movements.  The  inflamed  part,  there- 
fore, is  both  voluntarily  and  involuntarily  kept  at  rest  as  much  as 
possible.  This  is  done  by  muscular  action,  the  afferent  impression 
of  this  pain  being  reflected  to  all  the  associated  muscles  of  the  part 
to  restrain  their  action,  and  even  to  muscles  which,  though  not  usually 
connected  with  the  function  of  the  part  inflamed,  yet  may  disturb  it 


THE    SIGNIFICANCE    OF    PAIN  29 

by  their  movements.  Examples  of  the  fust  kind  are  seen  in  the 
fixity  of  joints  by  the  contraction  of  their  muscles  whenever  and  as 
long  as  the  joints  are  inflamed,  while  the  latter  is  shown  by  both  the 
local  or  general  rigidity  of  the  abdominal  muscles,  according  to  the 
local  or  general  state  of  inflammation  underneath.  You  can  exclude 
gastritis  as  the  cause  of  stomach  symptoms  if  there  be  no  rigidity  in 
the  epigastrium.  In  appendicitis,  from  the  commencement  of  the 
irritation  the  muscular  resistance  over  the  cecum  may  have  the  feel 
of  a  solid  tumor  much  before  there  has  been  time  for  exudation  or  pus 
formation.  A  number  of  other  characteristic  signs  are  thus  developed 
which  point  both  to  the  existence  of  inflammation  and  to  its  seat. 
There  is  no  part  of  the  body,  for  example,  so  often  moved  for  purposes 
of  attention  or  expression  as  the  head.  When,  therefore,  on  ap- 
proaching a  patient's  bed,  you  notice  that  he  turns  his  eyes,  but 
not  his  head  as  well,  to  look  at  you,  the  reason  may  soon  be  found 
in  rigidity  of  the  muscles  of  the  neck,  owing  to  meningitis.  It  is  a 
good  sign  of  improvement  in  such  a  case  when  his  head  acts  naturally 
with  his  eyes  or  nods  in  assent.  A  healthy  child  constantly  bends  or 
unbends  its  back,  but  a  child  carefully  picking  up  something  from 
the  floor  by  bending  its  knees  without  bending  its  back  should  lead 
you  to  examine  it  for  vertebral  disease.  There  may  be  lameness  from 
either  arthritis  or  sciatica  in  the  leg,  but  the  muscular  actions  are 
characteristically  different  in  each  of  these  inflammations.  I  need  not 
say  how  the  movements  of  the  ribs  in  breathing  are  watched  by  us  for 
the  same  reason  in  examining  for  phthisis,  pleurisy,  or  pleurodynia. 
Hence,  the  muscular  accompaniments,  so  to  speak,  of  inflammatory 
pain  are  of  much  service  in  diagnosis,  because  all  the  other  varieties 
of  pain  except  those  of  cramp  have  nothing  to  do  with  the  muscles. 
In  some  cases  of  hysteric  muscular  contractions  there  may  be  much 
complaint  of  pain;  but  the  other  features  of  these  cases  enable  us  readily 
to  distinguish  them  from  inflammatory  rigidity. 

The  third  great  characteristic  of  inflammatory  pain  is  that  it  is 
accompanied  by  disturbance  of  the  normal  function  of  the  affected 
part.  Now  this  does  not  happen  with  the  other  varieties  of  pain,  at 
least  as  a  characteristic  of  them.  Neuralgic  headache,  for  example, 
is  not  accompanied  by  delirium  or,  ordinarily,  by  intolerance  of  Kght 
or  sound,  as  the  headache  of  meningitis  is.  Neuralgic  pains  in  the 
spine,  in  the  arms,  or  in  the  legs  do  not,  like  inflammatory  pains, 
produce  stiffness  nor  fetter  the  movements  of  those  parts,  whose  chief 
functions  are  to  execute  movements.  So  the  diagnosis  between  pleu- 
risy and  pleurodynia  Hes  in  the  fact  that  the  pain  on  movement  of 


3° 


CLINICAL   MEDICINE 


the  ribs  in  pleurisy  causes  the  functional  symptom  of  cough,  while 
that  of  pleurodynia  does  not,  for  the  seat  of  the  pain  is  there,  not  in  the 
pleura.  Again,  when  a  pain  in  the  chest  is  accompanied  by  an  altered 
ratio  between  the  frequency  of  the  respiration  and  the  frequency  of 
the  pulse,  we  have  strong  reason,  from  this  significant  disturbance  of 
a  lung  function,  to  suspect  pneumonia.  If  inflammation  of  the  heart 
or  of  the  pericardium  causes  pain,  it  is  always  accompanied  by  signs 
of  disturbed  heart  action.  So  gastritis  cannot  cause  pain  without 
being  accompanied  by  symptoms  of  gastric  functional  disorder.  The 
same  is  true  of  peritonitis,  enteritis,  or  dysentery.  I  once  wondered 
why  a  patient  who  complained  of  attacks  of  severe  pain  just  above 
the  pubis  had  been  twice  sounded  by  surgeons  for  stone  in  the  blad- 
der, when  he  showed  no  signs  of  disturbed  function  in  the  bladder 
whatever.  It  proved  to  be  due  to  chronic  lead-poisoning  from  the 
prolonged  use  of  a  hair-dye. 

Besides  these  three  great  characteristics  of  inflammatory  pains, 
the  sensation  itself  often  varies  in  kind,  according  to  the  tissue  in- 
volved. The  rule  is,  the  softer  the  texture,  the  less  acute  the  pain; 
so  that  it  may  be  described  as  only  dull  and  heavy,  as  in  inflamma- 
tion of  the  liver  or  in  a  pneumonia  which  has  not  involved  the  pleura. 
In  inflammations  of  mucous  membranes  the  pain,  if  moderate  in  degree, 
is  more  like  a  diffused  soreness;  if  severe,  it  may  be  termed  ''burning." 
Whenever  griping  or  bearing-down  sensations  develop  it  is  because 
the  inflammatory  irritation  has  extended  from  the  mucous  membrane 
to  the  muscular  coat  of  the  wall  of  the  canal  or  viscus  which  the 
membrane  hues.  Pain  of  inflamed  serous  membranes  is  much  more 
acute  than  in  the  case  of  mucous  membranes,  and  is  apt  to  be  lanci- 
nating or  stabbing,  as  indicated  by  the  patient's  gesture.  Pain  of 
inflamed  fibrous  tissues,  such  as  muscular  fascia,  nerve-sheaths,  perios- 
teum, dura  mater,  etc.,  if  moderate,  is  of  a  dull  aching  character;  but 
if  severe,  is  very  violent,  on  account  of  the  unyielding  nature  of  the 
tissue.  A  serviceable  indication  of  the  seat  of  the  inflammatory  proc- 
ess is  afforded  by  the  susceptibility  of  patients  with  any  form  of 
fibrous-tissue  inflammation  to  changes  in  the  weather.  In  health 
there  is  a  perfect  adjustment  between  the  centrifugal  pressure  of  the 
circulation  and  the  centripetal  pressure  of  the  weight  of  the  atmo- 
sphere. Changes  in  the  latter,  as  indicated  by  the  fall  in  the  bar- 
ometer on  the  approach  of  a  storm,  are  readily  compensated  for  by  the 
nerve-fibrils  being  readily  removed  in  the  softer  tissues  from  unbal- 
anced intravascular  pressure,  but  not  so  in  the  denser  fibrous  tissues. 
Hence  the  good  but  inconvenient  barometers  which  a  gouty  man  has 


THE    SIGNIFICANCE    OF    PAIN  3 1 

in  his  toes,  which  may  ache  worse  while  the  sky  is  yet  clear,  ?jut 
which  he  knows,  from  experience,  means  that  the  clouds  are  on  their 
way.  So  a  patient  with  sciatica  finds  his  bed-covering  no  protection 
when  his  leg  wakes  him  in  the  middle  of  the  night  with  its  observations 
on  the  weather  out  of  doors.  It  is  well,  therefore,  to  ask  whether  a 
headache  complained  of  grows  worse  just  before  a  storm,  when  you 
have  reason  to  suspect  that  it  is  no  mere  functional  trouble,  but  a 
cephalalgia  of  syphiUtic  origin,  or  from  some  other  cause  of  pachy- 
meningitis. 

Inflammatory  pain  is  pecuharly  local  and,  therefore,  referred  to 
the  part  inflamed,  except  when  the  inflammatory  process  involves  the 
course  of  nerves.  In  that  case,  it  may  be  radiated  either  along  those 
nerves  directly  or  to  some  region  in  nervous  association  with  the  seat 
of  the  inflammation.  Thus,  the  pain  in  ulcerative  gastritis  is  often 
radiated  to  the  sixth  or  seventh  dorsal  vertebrae.  Inflammation  in- 
volving the  convex  surface  of  the  liver  affects  the  distribution  of  the 
right  phrenic  nerve  on  the  under  surface  of  the  diaphragm,  and  from 
there  may  radiate  to  the  top  of  the  right  shoulder  or  between  the 
scapulae.  Inflammation  of  the  vertebrae  sends  pain  to  the  anterior 
distribution  of  the  surface  nerves.  Inflammation  of  the  kidney  radi- 
ates pain  to  the  testicle  and  down  the  inside  of  the  thigh,  while  inflam- 
mation of  the  fundus  of  the  bladder  produces  pain  felt  in  the  head  of 
the  penis.  In  some  cases  of  inflammation  of  the  prostate  pain  is  felt 
in  the  sole  of  the  foot.  In  every  case,  however,  these  pains  can  be 
proved  not  to  belong  to  the  region  to  which  they  are  referred  by  the 
fact  that  the  patient  has  no  objection  either  to  movement  or  pressure 
of  the  part. 

The  treatment  of  inflammatory  pains  is  that  of  the  inflammation 
itself,  and  hence  often  different  from,  if  not  the  reverse  of,  the  treat- 
ment of  other  kinds  of  pain.  The  first  indication  is  rest,  including 
the  position  which  assures  most  rest.  After  a  rheumatic  carditis 
the  patient  had  better  stay  three  or  four  months  in  bed  if  he  still  has 
cardiac  pains  and  quickened  pulse.  Nothing  is  more  serviceable 
sometimes  in  the  later  stages  of  pleurisy  than  to  limit  as  much  as  pos- 
sible the  movements  of  the  ribs  by  firmly  strapping  the  whole  affected 
side  of  the  chest.  But  the  instances  in  which  this  principle  can  be 
applied  are  too  numerous  to  mention  here.  In  many  acute  inflamma- 
tions the  vascular  sedative  action  of  topical  bloodletting  is  often 
remarkably  effective  in  relieving  the  pain.  On  the  other  hand,  with 
the  pains  of  chronic  inflammations,  the  stimulant  effect  of  counterirri- 
tation  is  preferable,  according  to  the  rule  that  the  indications  in  the 


32  CLINICAL   MEDICINE 

treatment  of  chronic  inflammations  are  the  opposite  of  those  for  acute 
inflammations.  In  traumatic  lesions,  both  the  pain  and  the  inflam- 
mation are  generally  treated  best  by  the  local  application  of  ice-bags, 
but  cold  is  useless  when  the  inflammation  is  due  to  a  general  cause 
in  the  blood,  as  in  rheumatic  and  gouty  arthritis.  Cold  applica- 
tions should  be  discontinued  at  once  if  they  cause  a  neuralgic  pain 
to  take  the  place  of  an  inflammatory  pain.  Many  internal  inflam- 
matory pains  are  best  relieved  by  the  sedative  properties  of  moist 
heat  applied  to  the  surface,  as  by  poultices,  etc.,  according  to  the  gen- 
eral law  that  the  cutaneous  sensory  nerves  are  always  in  association 
with  the  vascular  nerves  of  the  parts  underneath.  The  chief  drug  for 
inflammatory  pains  is  opium.  Next  comes  aconite,  especially  in  serous 
membrane  and  cardiac  inflammations.  The  coal-tar  analgesics,  so 
valuable  in  the  other  kinds  of  pain,  are  comparatively  useless  in  inflam- 
matory pains. 

Pressure-pains,  as  their  name  implies,  are  due  to  the  encroach- 
ment of  tumors,  abscesses,  aneurysms,  or  other  causes  of  direct 
pressure  brought  to  bear  upon  nerves  anywhere  along  their  course. 
Their  chief  characteristic  is  that  they  are  essentially  continuous. 
Though  these  pains  may  be  aggravated  into  paroxysms  of  greater 
or  less  severity,  yet  they  differ  altogether  from  the  large  class  of 
neuralgic  pains  with  which  they  may  be  confounded  by  the  fact 
that  they  never  wholly  intermit.  There  always  is  some  uneasi- 
ness left  at  the  seat  of  pressure,  however  much  the  pain  has  lessened 
in  degree.  The  reason  why  they  are  mistaken  for  neuralgic  pains 
is  because  they  do  not  show  the  character  of  inflammatory  pains  in 
being  increased  by  pressure  or  movement,  or  by  producing  muscular 
stiffness,  except  sometimes  abdominal  rigidity  in  the  case  of  gastric 
or  pancreatic  tumors.  We  always,  indeed,  have  reason  to  suspect 
that  a  fixed  or  stationary  pain  is  something  more  than  functional,  and 
most  likely  due  to  an  organic  mischief,  however  hidden  that  may  be. 
On  the  other  hand,  pressure-pains  may  present  a  seeming  resemblance 
to  inflammatory  pains  when  the  pressure  mechanically  interferes  with 
the  function  of  the  parts  or  organs  implicated.  Thus,  in  brain  tumors 
or  abscesses  the  small  room  in  the  cranial  cavity  for  any  displace- 
ment may  cause  many  symptoms  of  functional  disorder  of  the  brain  to 
accompany  a  pressure-pain  there.  Except  in  the  case  of  brain  abscess, 
however,  the  absence  of  fever  and  of  other  accompaniments  of  inflam- 
mation win  ordinarily  suffice  to  indicate  the  true  nature  of  the  pain. 
In  other  parts  of  the  body  the  disturbance  of  function  caused  by  pres- 
sure is  different  from  that  caused  by  inflammation,  in  that  the  func- 


THE    SIGNIFICANCE    OF   PAIN  33 

tion  is  embarrassed,  rather  than  excited,  while  the  pains  are  evidently 
not  so  closely  connected  with  the  functional  actions  themselves  as  they 
are  in  inflammation. 

Pressure-pains  are  apt  to  radiate  more  widely  than  any  other 
kinds  of  pain  when  the  pressure  involves  large  trunks  or  plexuses 
of  nerves.  They  differ  in  such  cases  from  radiated  inflammatory  pains 
in  their  greater  variety  of  range.  But,  however  far  they  may  travel, 
they  are  always  characterized  by  having  a  central  focus  or  head- 
quarters where  pain  is  never  absent  and  to  which  they  can  be  traced. 
A  careful  examination  then  will  show  that,  whereas  pain  is  constant 
at  the  original  focus,  those  which  radiate  from  it,  though  they  may 
seem  much  more  severe,  are  quite  subject  to  variations.  Thus,  years 
ago  a  phthisical  patient  of  mine  began  to  have  agonizing  pains 
in  his  legs,  wJiich  he  very  distinctly  referred  to  both  sciatics.  At 
first  I  was  deceived  into  treating  him  for  sciatica  by  vigorous  local 
measures,  including  the  actual  cautery.  In  time  I  found  that  his 
sciatic  pains  were  too  paroxysmal  and  shooting  in  character  to  corre- 
spond to  local  neuritis,  and,  moreover,  that  the  characteristic  ten- 
derness on  pressure  along  the  course  of  these  nerves  if  inflamed  was 
not,  in  him,  at  all  well  defined.  Meantime  he  had  a  fixed  pain  in  the 
back  just  above  the  lumbar  vertebrae,  nothing  like  as  severe  as  in  the 
legs,  but  nevertheless  both  uniform  and  persistent.  Months  passed, 
and  then  the  development  of  a  soft  swelling,  divided  by  Poupart's 
ligament  in  his  right  groin,  explained  everything  as  due  to  the  progress 
-of  a  psoas  abscess.  I  have  always  since  searched  for  the  abiding  places 
of  pain,  no  matter  what  its  excursions  might  be. 

When  a  tumor  involves  in  its  growth  the  trunk  of  a  nerve,  it  some- 
times causes  trophic  changes  at  the  peripheral  distribution  of  the 
nerve  on  the  skin,  in  the  form  of  an  intractable  ulcer  or  as  a  herpetic 
eruption,  followed  by  persistent  local  anesthesia. 

Painful  cramps  are  a  variety  of  pressure-pains.  The  cramps 
are  generally  of  reflex  origin,  and  when  persistent  the  tonic  contrac- 
tion causes  much  wasting  of  the  implicated  muscles.  We  have  in  the 
persevering  use  of  the  warm-water  douche  a  specific  remedy  for  both 
this  pain  and  the  muscular  contraction  which  causes  it.  Pressure- 
pains  in  general  are  much  less  under  the  control  of  opium  than  inflam- 
matory pains.  The  pains  soon  get  used,  as  it  were,  to  the  opium,  and 
we.  have  to  increase  the  dose  to  get  the  desired  effect.  On  the  other 
hand,  antipyrin,  phenacetin,  and  the  other  coal-tar  derivatives, 
given  with  spirits  of  aromatic  ammonia,  are  often  of  considerable  ser- 
vice. This  is  especially  true  in  pains  caused  by  aneurysms. 
3 


34  CLINICAL   MEDICINE 

Stretching  Pains. — The  peculiarities  of  stretching  pains  are  well 
illustrated  during  the  passage  of  a  calculus  through  the  bile-duct  or 
the  ureter;  also  in  severe  sprains.  More  than  any  other  pains,  they, 
when  severe,  cause  great  faintness,  nausea  and  vomiting,  often  with 
chills  and  cold  sweats.  Unhke  either  inflammatory  or  pressure-pains, 
their  onset  is  usually  sudden,  and  in  the  stretching  of  narrow  ducts 
painful  spasms  in  them  so  commonly  develop  that  the  attacks  have  a 
pronounced  paroxysmal  character,  whence  the  name  "colics"  is  de- 
rived. The  sufferers  show  plainly  enough  by  doubhng  themselves 
upon  the  affected  part  or  by  firmly  pressing  their  hands  over  it  that 
the  pains  are  not  inflammatory.  Meantime  the  characteristic  radia- 
tions of  the  pains  are  of  much  diagnostic  value  in  distinguishing  either 
hepatic  or  renal  colics  from  each  other  and  from  other  painful  affec- 
tions in  the  abdomen,  being  in  the  hepatic  variety  from  near  the  um- 
bilicus directly  through  to  the  back  and  upward  between  the  scapulae, 
and  in  the  renal  from  the  back  down  to  the  groin,  with  retraction  of 
the  testicle,  and  radiated  also  to  the  inner  aspect  of  the  thigh.  In 
sprains,  at  the  onset  there  occurs  a  marked  superficial  tenderness  of  the 
skin,  which,  however,  passes  off  in  a  few  hours,  but  which  may  serve, 
at  the  ankle,  for  instance,  to  show  that  the  injury  is  a  sprain  rather  than 
a  fracture.  The  pains  of  so-called  myalgia,  so  common  in  women  with 
feeble  muscular  development,  felt  at  the  attachments  of  the  abdominal 
muscles  to  the  ribs  or  along  the  attachments  of  the  erectors  of  the 
spine,  are  virtually  stretching  pains  due  to  an  undue  pull  upon  ten- 
dinous textures  from  deficient  muscular  support.  Cutaneous  hj^er- 
esthesia,  therefore,  is  very  common  at  the  places  where  the  pains 
are  most  felt,  and  the  patients  often  complain  of  the  wearing  or  exhaust- 
ing nature  of  these  pains,  which,  moreover,  show  that  they  are  not 
properly  neuralgic,  from  their  having  no  tendency  to  shift.  In  the 
treatment  of  biHary  or  renal  colics  the  first  indication  is  to  prevent 
the  spasms  which  induce  the  paroxysms  of  pain  and,  moreover,  hin- 
der the  onward  passage  of  the  calculus.  This  is  best  done  by  arrest- 
ing the  afferent  impression  of  pain  which  evokes  the  motor  effect  of 
spasm,  and  we  have  nothing  like  a  hypodermic  of  morphin,  with 
atropin,  for  accompHshing  this  purpose.  Next  follows  the  excito- 
motor  paralyzer,  warm  water.  In  biliary  and  renal  colics  the  sudden 
cessation  of  pain  generally  indicates  that  the  calculus  has  passed  cut 
of  the  duct,  and  hence  is  much  more  reassuring  than  sudden  cessa- 
tion of  a  severe  inflammatory  pain,  for  that  may  mean  that  gangrene 
has  supervened.  Sprains  are  best  treated  by  douches — of  hot  water 
when  acute;  of  cold,  when  chronic.     Local  apphcations  of  belladonna 


THE    SIGNIFICANCE    OF    PAIN  35 

or  of  stramonium  ointments  or  liniments,  with  the  addition  of  chloral, 
may  relieve  better  than  the  lead-and-opium  lotion  so  useful  in  in- 
flammations. For  the  same  reason  belladonna  plasters  are  beneficial 
in  spinal  myalgia.  In  myalgia,  however,  the  first  indication  is  to 
develop  and  strengthen  the  muscles  by  massage,  or  by  alternate  exer- 
cise and  rest,  combined  with  the  great  restorer  of  weakened  muscles, 
the  oxygen  of  the  open  air. 

Neuralgic  Pains. — There  is  no  term  which  needs  definition  more 
than  that  of  "neuralgia."  Etymologically,  it  may  apply  to  any  pain 
in  a  nerve,  and  hence  we  find  it  given  to  the  most  diverse  kinds,  from 
tic  douloureux  to  the  pains  caused  by  tumors.  It  ought  to  be  cleared 
of  all  such  vagueness  of  meaning,  because  true  neuralgic  pains  have  a 
wholly  different  causation  from  either  inflammatory,  pressure-,  or 
stretching  pains,  and  hence  demand  different  treatment.  Thus,  in 
the  first  place,  they  present  none  of  the  signs  of  inflammation,  no  rise 
of  temperature,  no  swelhng  or  local  infiltration,  no  objection  to  press- 
ure, but  the  reverse;  likewise,  none  to  movement,  but  often  here  also 
the  reverse,  and  they  are  not  accompanied  by  any  characteristic 
disturbance  of  function  in  the  parts  which  they  affect.  On  this 
account  it  is  erroneous  to  include  among  neuralgias  a  whole  group  of 
inflammatory  conditions  of  nerves  or  nerve  gangha,  such  as  t>^ical  tic 
douloureux  or  so-called  trigeminal  neuralgia,  in  which  the  different 
branches  of  the  trigeminus,  and  often  the  gasserian  ganghon  itself, 
are  the  seats  of  intense  and  disorganizing  inflammation. 

In  this  affection — namely,  trigeminal  neuralgia — the  paroxysms  of 
pain  are  particularly  excited  by  the  functional  movements  of  the 
facial  muscles,  such  as  in  chewing,  opening  the  mouth  for  speaking, 
or  even  by  the  movements  of  facial  expression  or  emotion,  etc.  More- 
over, whenever  the  affected  branches  of  the  trigeminus  are  superficial 
enough  for  us  to  press  upon  them  we  find  them  exquisitely  tender,  as 
at  Valleix's  points.  The  same  may  be  said  of  most  cases  of  so-called 
brachial  neuralgia,  where  the  arm  has  to  be  kept  as  still  as  the  leg 
in  sciatica  to  prevent  the  paroxysms  of  pain.  Likewise,  most  cases 
of  "cervico-occipital  neuralgia"  are  really  cases  of  neuritis,  and  should 
be  treated  accordingly. 

Unlike  inflammatory,  pressure-,  or  stretching  pains,  true  neuralgic 
pains  are  much  less  local,  and  many  of  them  are  prone  to  wander 
about.  This  feature  alone  may  serve  to  demonstrate  their  nature,  for 
frequently  they  shift  their  seat  altogether,  wholly  disappearing  from 
one  locality,  to  develop  with  just  the  same  symptoms  and  severity 
in  quite  another  part.     In  this  respect  they  are  readily  distinguishable 


36  CLINICAL   MEDICINE 

from  the  pains  which  radiate  from  an  inflammatory  or  pressure  focus. 
One  notable  distinction  of  neuralgic  pains,  however,  lies  in  the  sig- 
nificant fact  of  intermittency .  Neither  an  inflammatory,  nor  a  pressure-, 
nor  a  stretching  pain  can  intermit;  they  can  only  remit  or  else  cease  with 
the  cessation  of  their  cause.  Neuralgic  pains,  on  the  other  hand, 
come  and  then  go  entirely,  leaving  the  patients  as  free  from  them, 
temporarily  at  least,  as  if  they  had  never  experienced  them.  No  one, 
for  example,  can  foretell  that  the  vivacious  lady  whom  he  meets  in 
company  will  be  entirely  prostrated  the  next  day  with  a  severe  head- 
ache, and  then  two  days  afterward  be  as  free  from  it  as  ever.  This 
fact  about  many  neuralgias  is  very  suggestive  of  their  toxic  origin,  for 
it  is  only  in  chronic  toxemia  that  we  have  similar  cumulative  results 
leading  to  nervous  explosions,  so  to  speak;  as,  for  instance,  uremic  con- 
vulsions or  attacks  of  gouty  asthma. 

We  would  divide  neuralgic  pains  into  the  febrile  toxic  and  the 
non-febrile  toxic.  Examples  of  the  first  are  found  in  the  aches  pro- 
duced by  the  poisons  which  cause  fever.  Frontal  headache,  lasting 
for  more  than  twenty-four  hours  and  accompanied  by  a  rise  of  tem- 
perature, with  a  general  aching  in  the  back  and  Hmbs,  should  lead  us 
at  once  to  suspect  a  febrile  connection.  If  it  lasts  three  days  or  more 
it  must  be  due  to  such  a  cause.  These  pains  are  in  no  sense  inflamma- 
tory, for  they  cause  great  restlessness,  the  patients  tossing  about  in 
bed  on  their  account  and  not  on  account  of  the  fever.  Though  in 
most  specific  fevers  these  headaches  last  longer  than  most  neuralgiac 
pains,  yet  they  always  cease  before  the  fever  ceases.  The  best 
medicinal  remedies  for  them  are  phenacetin  with  ammonium  bromid, 
or,  in  epidemic  influenza,  phenacetin  with  aconite,  and  a  small  dose 
(i  gr.)  of  Dover's  powder.  Cold  applications  to  the  aching  head 
are  often  very  grateful. 

The  second  class  of  toxic  neuralgias  are  the  non-febrile,  of  which 
a  good  example  is  found  in  the  truly  periodic  neuralgias,  or  those 
which  come  on  at  definite  times  of  the  twenty-four  hours,  and  then 
subside  hke  an  attack  of  ague.  It  is  natural,  therefore,  to  surmise  that 
they  have  some  connection  with  malarial  infection,  but  in  many  cases 
this  is  not  plainly  demonstrable,  and,  moreover,  notwithstanding  they 
may  be  very  severe,  they  most  commonly  are  not  accompanied  by  rise 
of  temperature.  Some  severe  examples  of  this  kind  I  have  found  occur- 
ring from  influenzal  infection.  They  may  attack  the  head,  the  sides 
of  the  chest  or  abdomen,  or  be  located  along  the  spine  or  in  the  pelvis. 
I  have  not  met  with  more  violent  cases  of  pain  than  in  some  of  these 
patients,  whom  I  have  seen  both  in  my  own  practice  and  frequently 


THE   SIGNIFICANCE    OF   PAIN  37 

in  consultation.  In  the  latter  cases  I  have  learned  that  quinin,  War- 
burg's tincture,  arsenic,  and  the  coal-tar  analgesics  had  ?jeen  previously 
administered,  often  in  heroic  doses,  without  any  effect  toward  prevent- 
ing or  mitigating  the  attacks,  and  hence  I  am  glad  to  say  that  I  con- 
sider ergot  in  full  doses  to  be  a  true  specific  for  periodic  neuralgias, 
whatever  their  seat  be.  A  dram  of  the  fiuidextract  should  be  taken 
every  two  hours,  with  a  dram  of  elixir  of  cinchona  in  water,  to  prevent 
nausea.  If  the  stomach  does  not  tolerate  the  ergot,  it  may  be  ad- 
ministered per  rectum  in  2  oz.  of  water.  The  first  dose  should  be 
taken  at  the  very  beginning  of  the  onset  of  the  pain,  and  if  that  suf- 
fices to  arrest  it  a  second  dose  is  not  needed,  but  with  some  it  requires 
three  doses.  It  is  curious  that  in  many  cases  I  have  found  that  12  gr. 
of  quinin  will  cinchonize  patients  who  have  just  taken  ergot,  when 
doses  of  30  gr.  taken  before  had  not  done  so. 

Migrainous  headaches  are  essentially  toxic  in  their  origin  and  due 
to  perversions  in  gastro-intestinal  digestion,  causing  absorption  into 
the  blood  therefrom  of  poisons  which  at  a  certain  point  of  accumula- 
tion bring  on  the  attack.  Like  gouty  or  Hthemic  derangements,  they 
are  very  commonly  due  to  constitutional  or  hereditary  tendencies. 
Ergot  is  here  also  a  specific  for  the  attacks  themselves,  administered 
as  above  recommended  for  periodic  neuralgias,  but  in  many  cases 
we  may  succeed  as  well  with  10  or  15  gr.  of  antipyrin  and  a  teaspoonful 
of  aromatic  spirits  of  ammonia,  taken  early  with  the  first  symptoms, 
when  the  patient  should  at  once  He  down,  and  then  repeat  the  dose  in 
two  hours  if  required.  But  the  true  treatment  of  migraine  is  prophy- 
lactic, by  a  prolonged  and  systematic  course  of  intestinal  antiseptics. 

Patients  with  a  persistent  rapid  action  of  the  heart,  without  fever 
and  without  cardiac  or  renal  disease  to  account  for  the  tachycardia, 
are  very  commonly  great  sufferers  from  neuralgic  pains  in  the  various 
parts  of  the  body.  This  is  well  shown  in  many  cases  of  Graves'  dis- 
ease, both  before  and  after  the  development  of  thyroid  symptoms, 
but  such  neuralgias  may  be  equally  present  in  patients  with  such  tachy- 
cardia who  never  show  either  exophthalmia  or  goiter.  Here  intestinal 
antiseptics,  such  as  weekly  mercurial  purgation,  perseveringly  followed 
up  by  phenol  or  naphthol  bismuth,  bismuth  salicylate,  strontium  sal- 
icylate, salol,  etc.,  and  total  abstinence  from  butcher  meat,  taking  milk 
instead,  will  cure  both  the  neuralgias  and  the  overaction  of  the  heart. 

Gastric  acidity  is  apt  to  produce  frontal  and  temporal  headaches, 
while  occipital  headaches,  accortipanied  by  tenderness  on  pressure  upon 
the  eyeballs,  are  distinctive  of  intestinal  fermentation.  In  some  cases 
severe  attacks  from  like  causes  take  place  in  the  stomach,  which  go  by 


38  CLINICAL  MEDICINE 

the  name  of  gastralgia.  The  rehef  following  upon  the  administration 
of  2-V-gr-  closes  of  arsenous  acid  in  gastralgia  would  seem  to  indicate  its 
causation,  for  arsenic  very  quickly  arrests  any  form  of  fermentation. 

Under  the  head  of  non-febrile  toxic  neuralgias  would  come  those 
occasioned  by  chronic  metallic  poisoning,  especially  that  by  lead,  in 
which  wandering  pains  occur  which  are  apt  to  be  mistaken  for  rheuma- 
tism, though  undoubtedly  they  have  more  relationship  to  gouty  neural- 
gias, as  lead-poisoning  is  one  of  the  recognized  causes  of  the  gouty 
state.  On  the  other  hand,  the  abdominal  cramps  are  just  as  specific 
effects  of  plumbism  as  its  special  paralyses  are.  Lastly,  among  these 
non-febrile  toxic  neuralgias  we  should  not  forget  those  due  to  B right's 
disease  and  to  diabetes.  Pain  in  the  back  of  the  head  is  common  in 
Bright's  disease,  and  is  not  necessarily  of  dangerous  import.  Not  so, 
however,  when  general  pains  are  complained  of  in  every  part  of  the 
body,  for  these  may  presage  a  near  fatal  issue,  as  their  frequent  asso- 
ciation with  convulsions  shows.  On  the  other  hand,  the  local  pains 
occurring  in  diabetes  not  infrequently  are  due  to  actual  neuritis. 

The  third  class  of  neuralgic  pains  are  the  non-toxic.  They  some- 
times appear  to  be  purely  reflex,  as,  for  example,  a  true  trigeminal 
neuralgia  caused  by  a  necrosed  piece  of  bone  in  the  nares,  and  which 
is  cured  by  its  removal.  Under  this  class  also  come  headaches 
from  eye-strain,  about  which  we  hear  so  much.  Of  one  peculiar 
form  of  headache  I  have  met  several  instances.  The  ache  seems 
to  begin  at  the  root  of  the  nose,  and  passes  horizontally  backward 
to  the  occiput.  It  is  always  aggravated  by  prolonged  bending  for- 
ward of  the  head,  as  in  writing,  etc.,  and  has  a  special  tendency  to 
cause  incapacity  for  mental  exertion.  In  each  of  my  cases  it  was 
found  associated  with  a  nasal  obstruction  from  old  fractures  of  the 
nasal  bones,  and  the  headaches  were  cured  by  operation. 

One  important  form  of  neuralgic  pains  of  a  non- toxic  character  is 
that  due  to  a  degenerative  process  set  up  in  sensory  nerves  and  nerve- 
roots,  such  as  the  Mghtning  pains  of  tabes.  The  degenerative  processes 
themselves  may  have  been  due  originally  to  a  toxic  infection,  such  as 
syphilis,  but  this  no  longer  operates  as  a  cause  of  the  pain.  The  patients 
rub,  seize,  or  grab  the  affected  part  as  if  they  were  desperately  bent 
on  arresting  the  pain  in  its  flight.  For  the  pains  of  tabes  the  coal- 
tar  analgesics  are  often  very  effective,  particularly  acetanilid.  Nitrate 
of  silver  also  often  affords  decided  relief,  and  it  is  curious  that  this 
drug  will  sometimes  unmistakably  mitigate  pressure-pains  caused 
by  a  tumor  involving  the  roots  of  a  spinal  nerve,  as  I  have  had  occa- 
sion to  note  in  several  instances. 


THE    SIGNIFICANCE    OF    PAIN 


39 


I  surmise  also  that  the  rapidly  fatal  form  of  angina  pectoris  is 
likewise  due  to  degenerative  disease  of  the  intrinsic  cardiac  nerves. 
Some  writers  seem  inclined  to  merge  this  most  specific  disease  of 
angina  pectoris  into  a  mere  general  symptom,  and  to  confound  with 
it  all  forms  of  cardiac  pains  not  due  to  inflammatory  processes.  Thus, 
the  paroxysmal  anginose  pains  in  a  case  of  combined  aortic  stenosis 
and  incompetence  are  pronounced  indistinguishable  from  those  of 
angina  pectoris.  Let  the  mitral  valve,  however,  begin  to  leak  also  in 
these  cases,  and  so  reHeve  the  intraventricular  pressure,  and  the 
pains  vanish  altogether.  I  cannot  but  regard  them,  therefore,  as 
wholly  analogous  to  the  cardiac  pains  in  patients  with  general  arterio- 
sclerosis and  high-tension  pulse,  and  which  are  brought  on  by  over- 
work of  the  heart  muscle,  just  as  cramps  may  be  induced  in  the 
calves  of  the  legs  by  too  prolonged  dancmg.  But  the  clinical  histories 
of  typically  fatal  attacks  of  angina  pectoris  are  totally  different.  Thus, 
one  of  my  patients,  who  had  never  experienced  a  single  symptom 
of  heart  trouble  before,  was  suddenly  attacked  on  wakiag  in  the 
morning,  while  resting  quietly  in  bed,  with  the  first  pang,  which  so 
terrified  her  with  a  sense  of  impending  death  that  she  sent  for  me. 
I  saw  her  three  hours  afterward,  when  she  was  quite  free  from  pain, 
and  when  she  gave  me  a  most  inteUigent  account  of  it.  I  advised 
her  to  remain  in  bed  and  left  a  prescription  for  amyl  nitrate,  to  use 
in  case  of  a  return  of  the  pain.  Ten  minutes  afterward  she  suddenly 
died.  Another  was  a  gentleman  who,  without  any  previous  warning, 
was  first  seized  with  a  short  paroxysm  while  talking  to  a  friend.  I 
saw  hiin  soon  afterward,  and  his  description  of  the  attack  left  no 
doubt  of  its  nature.     Ten  hours  afterward  he  suddenly  died. 

One  of  the  striking  accompaniments  of  this  fatal  pain  is  an  instruc- 
tive apprehension  on  the  part  of  the  patient  of  impending  death, 
one  gentleman  of  my  acquaintance  remarking  that  he  did  not  know 
that  death  could  be  so  painful,  and  a  moment  afterward  he  breathed 
his  last. 

Neuralgic  pains  in  different  parts  of  the  body  are  very  character- 
istic of  impoverishment  or  anemic  states  of  the  blood,  one  author 
remarking  that  neuralgia  is  the  cry  of  a  nerve  for  more  or  better  blood. 
But  while  neuralgias  are  very  common  in  anemic  states,  yet  they  are 
not  always  characteristic  of  them. 

Thus,  I  have  met  with  instances  of  pernicious  anemia  in  which  there 
was  no  neuralgia  complained  of  from  the  beginning  to  the  fatal  end  of 
the  disease.  On  the  other  hand,  blood  impoverishment  is  often  the 
direct  result  of  the  toxemias,  which  also  cause  toxic  neuralgias,  and 


40  CLINICAL  MEDICINE 

lb 

hence  I  would  paraphrase  the  sa3dng  that  "neuralgia  is  the  cry  of  a 
nerve  for  more  blood"  into  a  "cry  for  purer  blood."  Iron,  cod-liver 
oil,  etc.,  are  good  remedies  in  these  cases  by  improving  that  general 
nutrition,  which  is  Nature's  most  effective  antiseptic. 

Subjective  Pains. — In  a  sense,  all  pains  are  subjective,  for  if  by 
severing  the  nerves  we  interrupt  the  conduction  to  the  sensorium  of  the 
severest  inflammatory  or  pressure-pain,  there  will  then  be  felt  no  pain 
at  all.  But  as  the  sensation  of  pain  itself  is  a  centric  function,  why 
may  its  origin  not  be  in  a  disturbance  of  the  pain  centers  themselves 
without  an  antecedent  peripheric  irritation?  Certainly  we  must  admit 
that,  for  example,  in  many  cases  of  hysteric  hemi-anesthesia  this 
sensory  derangement  evidently  starts  from  a  cortical  area,  but  if  so, 
then  a  hyperesthesia  amounting  to  severe  pain  is  just  as  likely  to  own  a 
similar  origin.  I  have  no  doubt  that  this  is  sometimes  the  case  also 
in  patients  who  cannot  properly  be  termed  hysteric,  but  who  are 
said  to  have  a  highly  nervous  organization,  and  in  whom  some  vio- 
lent attacks  of  pain  are  brought  on  by  strong  emotion.  The  cerebral 
relations  of  these  pains,  however,  make  them  so  Hkely  to  be  influenced 
by  purely  cerebral  states,  being  often  both  induced  and  removed  by 
mental  impressions  alone,  that  we  are  apt  to  regard  them  as  more 
or  less  imaginary.  This,  however,  is  a  less  common  mistake  now 
than  formerly,  as  the  pathology  of  hysteria  itself  is  becoming  better 
understood.  A  motor  paralysis  of  hysteric  origin  is  as  real  as  any 
other  paralysis,  as  in  the  case  of  a  motionless  vocal  chord  in  hysteric 
aphonia,  where,  of  course,  the  patient  knows  nothing  about  the 
paralyzed  part  which  he  has  never  seen.  Likewise,  hysteric  pains 
may  be  as  unimaginary  as  such  motor  derangements  are.  Owing, 
however,  to  their  cerebral  origin,  they  are  far  more  intimately  associ- 
ated with  mental  or  emotional  states  than  is  possible  with  any  other 
class  of  pains.  The  patients  think  them,  so  to  speak,  as  much,  if  not 
more,  than  they  feel  them,  and  so  are  often  led  to  refer  them  to  any 
part  of  the  body  by  simple  mental  suggestion  or,  what  amounts  to 
the  same  thing,  forgetting  one  pain  while  their  attention  is  directed  to 
another.  Hysteric  pains,  therefore,  may  simulate  all  varieties  of 
pain,  one  after  the  other,  in  such  succession  that  a  beginner  in  practice 
may  be  much  puzzled  by  them,  especially  when  complained  of  about 
the  joints  or  in  the  abdomen.  Hence,  a  careful  observation  of  the 
mental  accompaniments  of  the  pain  is  the  surest  way  to  arrive  at  the 
diagnosis  of  its  hysteric  nature.  Thus,  real  objective  pains  are  very 
concisely  described  with  a  few  characteristic  gestures  and  equally 
few  words.     Subjective  pains,  on  the  other  hand,  are  described  with 


THE   SIGNIFICANCE   OF   PAIN  4 1 

many  a  theatric  gesture  and  with  a  copious  variety  of  terms,  which 
all  go  to  show  how  much  the  patients  occupy  their  minds  with  dwell- 
ing upon  them.  This  of  itself  is  enough  to  strengthen  the  presump- 
tion of  their  subjective  character,  for  objective  pains  always  inhibit 
both  thought  itself  and  its  expression.  The  description  of  a  hvely 
disturbance  in  the  great  toe  by  gout  is  generally  hmited  to  interjec- 
tions or  expletives;  while,  on  the  contrary,  the  hysteric  patient 
seems  to  enjoy  talking  about  her  unexampled  sufferings  by  the  hour, 
especially  to  a  sympathetic  Hstener.  The  treatment  of  hysteric 
pains  is  to  be  that  of  hysteria  itself.  Nothing  is  more  useless  or  mis- 
chievous than  to  relieve  them  by  anodynes  and  particularly  by  opiates. 
Cutaneous  Reflex  Pains. — Dr.  Henry  Head,  Registrar  of  the 
London  Hospital,  has  directed  the  attention  of  the  profession  to  a  very 
interesting  class  of  pains  which  are  eUcited  by  hghtly  pressing  the 
skin  or  touching  it  with  the  head  of  a  pin.  Nothing,  therefore,  could 
be  so  extremely  peripheral  as  these  pains,  but  their  interest  lies  in  the 
fact  that  only  deep-seated  visceral  disease  will  cause  them.  When 
these  pains  are  produced  by  the  light  appHcation  of  a  large-sized  pin's 
head,  the  patient  not  being  allowed  to  see  it  done,  they  are  complained 
of  as  a  burning  or  smarting  sensation,  which  when  pronounced  leads 
the  patient  to  beg  that  the  experiment  be  not  repeated.  I  have  myself 
repeatedly  confirmed  this  curious  phenomenon.  Thus,  a  man  with  a 
calculus  in  the  left  kidney  always  swore  when  the  pin's  head  touched 
the  tip  of  the  left  twelfth  rib.  The  special  interest  of  Dr.  Head's 
researches  lies  in  his  demonstration  of  the  definite  limitation  of  the 
cutaneous  areas  of  these  pains  to  the  distribution  on  the  skin  of 
nerves  associated  with  the  nerves  of  the  corresponding  internal  organs. 
This  distribution  is  not  according  to  the  segmental  distribtuion  of  the 
spinal  nerves,  but  according  to  certain  definite  associations  of  nerves 
which  are  curiously  illustrated  by  the  eruptions  of  herpes  zoster,  which 
Dr.  Head  shows  correspond  to  the  different  cutaneous  areas  of  reflex 
hyperesthesia  in  organic  visceral  disease.  Thus,  I  found  in  a  patient 
with  gastric  ulcer  these  well-marked  cutaneous  pains  over  the  ensi- 
form  cartilage,  at  the  junction  of  the  eighth  rib  with  its  cartilage,  and 
in  the  back  on  a  level  with  the  angle  of  the  scapula.  Dr.  Head  has 
mapped  out  a  most  elaborate  delineation  of  the  areas  on  the  skin,  in 
which,  if  these  pains  are  present,  we  may  thus  diagnose  from  what 
internal  viscera  they  proceed,  but  we  cannot  more  than  allude  to  them 
here  on  account  of  the  need  of  constant  reference  to  his  charts  to 
Olustrate  the  statements  which  he  makes.  In  trying,  however,  to 
verify  these  observations  myself,  I  have  found  that  when  these  pains 


42  CLINICAL  MEDICINE 

are  present  in  the  specific  localities  which  he  describes,  they  afford 
very  valuable  indications,  but  their  absence  is  no  proof  whatever  of 
the  absence  of  organic  visceral  disease.  Thus,  only  about  i  out  of 
8  cases  of  undoubted  ulcer  of  the  stomach  showed  these  painful  skin 
symptoms,  and  then  not  unless  the  local  pain  in  the  stomach  itself 
was  well  marked.  Similarly,  in  heart  disease,  aortic  aneurysm,  and 
other  internal  affections  the  pain  thus  reaches  the  skin  only  when  it 
first  has  been  severe  within.  Nevertheless,  it  is  a  very  suggestive  sub- 
ject and  merits  further  investigation,  not  only  for  the  aid  which  it  may 
afford  in  the  diagnosis  of  internal  organic  disease,  but  also  in  the  rela- 
tion of  many  pains  about  the  head  which  have  been  classed  as  local 
neuralgias,  but  which  may  thus  be  shown  to  be  associated  with  defi- 
nite disturbances,  sometimes  functional  as  well  as  organic,  in  the 
thoracic  and  abdominal  viscera. 

THE  SIGNIFICANCE  OF  EMACIATION 

One  of  the  general  conditions  which  is  at  once  recognized  as  an 
evidence  of  disease  is  emaciation.  It  is  always  a  serious  condition 
when  present,  even  when  we  have  reason  to  beHeve  that  it  will  soon  be 
recovered  from.  It  is  usually  described  as  a  loss  of  flesh  or  that  the 
patient  has  grown  thin.  But  this  is  too  partial  a  designation,  because 
actual  emaciation  includes  much  more  than  loss  of  fat  or  even  of 
muscle.  To  be  thin,  in  the  sense  of  having  but  little  fat,  may  be  quite 
compatible  with  good  health  in  many  persons,  because  on  examination 
their  muscles  and  bones  are  found  both  well  developed  and  well  nour- 
ished. True  emaciation,  on  the  other  hand,  is  characterized  by  loss 
of  bulk  in  every  tissue  of  the  body  except  one,  and  that  an  important 
exception  from  its  practical  bearings,  as  we  shall  see.  As  each  tissue 
•becomes  involved  in  the  wasting,  special  compHcations  arise  therefrom 
due  to  the  emaciation  itself,  whatever  its  original  cause  may  be. 
Clinically,  therefore,  emaciation  sometimes  may  assume  the  charac- 
ter of  a  concomitant  disease  with  important  indications  of  its  own  for 
treatment;  for  not  infrequently  particular  conditions  accompanying 
emaciation  become  themselves  grave,  if  not  fatal,  elements  in  the  case. 

The  fact  of  emaciation  is  best  revealed  by  the  hands.  The  face, 
especially  if  not  known  to  the  physician  before,  may  not  suggest  the 
general  wasting  present,  but  the  appearance  of  the  backs  of  the  hands 
is  unmistakable.  Instead  of  a  uniform  and  shghtly  convex  surface, 
they  show  deep  furrows  between  the  metacarpal  bones  from  atrophy 
of  the  interossei  muscles.  On  extending  the  fingers,  only  the  condyles 
touch  each  other.     On  the  under  surface  the  wasting  of  the  palmar 


THE    SIGNIFICANCE    OF    EMACIATION  43 

muscles  renders  the  natural  concave  shape  of  the  bones  so  pronounced 
that,  where  extreme,  the  whole  hand  resembles  the  crooked  claws  of  a 
bird. 

There  is  no  morbid  condition  in  which  a  knowledge  of  its  etiology- 
is  of  such  practical  importance;  but  though  cases  of  emaciation  are 
very  numerous,  their  usual  causes  are  so  few  that  they  can  be  re- 
membered readily  when  we  would  distinguish  to  which  of  them  the 
condition  is  due.  The  ordinary  causes  of  emaciation  are  six  in  num- 
ber, as  follows: 

1.  Bacterial  infection. 

2.  Malignant  diseases. 

3.  Gastro-intestinal  disorders. 

4.  Jaundice  and  cirrhosis  of  the  liver. 

5.  Diabetes. 

6.  Graves'  disease. 

Bacterial  Infection. — Fully  75  per  cent,  of  all  cases  of  emaciation 
are  owing  to  the  direct  solvent  action  of  bacterial  toxins  upon  the 
body  cells.  This  property  of  these  toxins  is  illustrated  by  the  extreme 
emaciation  following  experimental  injection  in  animals  of  various  bac- 
teria even  in  attenuated  cultures  if  the  injections  be  long  continued. 
That  no  other  agency  can  be  operative  in  this  instance  is  plain  from 
the  animals  being  in  a  healthy  condition  when  the  experiments  are 
begun,  and  also  by  the  fact  that  the  emaciation  will  progress  if  the 
injections  are  kept  up,  though  the  animal  has  been  rendered  immune 
against  the  original  infection,  thus  showing  that  the  antitoxin  gener- 
ated is  powerless  against  the  wasting  itself. 

The  most  appreciable  sign  of  this  poisoning,  but  which  occurs 
also  in  emaciation  from  other  causes,  is  a  general  disappearance  of  fat. 
But  this  involves  a  loss  of  the  great  subcutaneous  cushion  of  fat  which 
is  so  necessary  for  the  healthy  condition  and  blood-supply  of  the  skin 
and  of  its  appendages.  The  skin  thus  loses  its  vitahty  and  becomes 
readily  infected  by  scratches  or  slight  injuries,  particularly  if  it  be  not 
kept  scrupulously  clean.  Ere  long  another  complication  ensues  by  the 
bones  coming  in  contact  with  the  thinned  skin  until  an  intractable 
ulceration  follows.  Bed-sores  are  never  trivial  things,  and  repeatedly 
have  I  known  them  to  become  the  cause  of  death.  Hence  in  every  case 
of  wasting  fever  the  patient's  back  should  be  examined  twice  daily 
and  the  first  signs  of  redness  over  subjacent  bones  noted.  Fever 
being  a  process  which  especially  involves  the  muscular  tissues,  the 
patients  are  prone  from  muscular  weakness  to  lie  unchangeably  on 
the  back.     In  health,  frequent  shifting  of  posture  is  secured  by  the 


44  CLINICAL  MEDICINE 

normal  intolerance  of  the  surface  nerves  to  too  continued  pressure,  but 
in  fever,  blunted  sensation  is  the  rule,  and  unless  watched  any  patient 
with  a  prolonged  febrile  disease  is  apt  to  develop  ulceration  there 
which  may  heal  only  with  difficulty.  The  surest  preventive  of  bed- 
sores, therefore,  along  with  maintaining  constant  asepsis  of  the 
skin,  is  frequent  change  of  position.  Thus,  serious  examples  of  this 
trouble,  though  not  due  either  to  emaciation  or  to  fever,  are  the  bed- 
sores which  accompany  transverse  myelitis  so  generally  that  many 
regard  them  as  inevitable  with  this  spinal  lesion.  But  Dr.  Starr 
("Organic  Nervous  Diseases,"  p.  50)  mentions  the  case  of  a  patient  of 
his  in  whom  the  simple  expedient  of  turning  him  every  half-hour  day 
and  night,  and  wiping  o&  the  skin  Hghtly  each  time  that  he  was  turned, 
prevented  for  four  years  the  development  of  any  skin  abrasion. 

Another  complication,  giving  rise  to  great  distress  to  those  who 
are  confined  to  bed,  especially  with  a  chronic  wasting  disease,  is  the 
supervention  of  general  neuralgic  pains  which  interfere  with  both  rest 
and  sleep.  The  true  cause  of  these  pains  is  often  not  recognized,  nor, 
therefore,  how  they  best  can  be  remedied.  As  remarked  above, 
there  is  one  tissue  which  does  not  emaciate,  and  that  is  nervous  tissue. 
This  is  in  keeping  with  the  fact  that  in  animals  dying  of  starvation 
every  tissue  loses  weight  and  bulk  except  the  brain  and  spinal  cord. 
In  emaciation,  therefore,  the  nerves  are  all  there,  but  now  no  longer 
protected  from  the  pressure  of  the  bones  by  layers  of  fat  and  muscle. 
The  most  severe  aching,  wearing  pains  are  thus  kept  up  day  and 
night.  Hence  I  cannot  too  earnestly  recommend  some  simple  pro- 
cedures which  I  have  found  to  greatly  mitigate  these  pains.  I 
have  long  provided  for  emaciated  phthisical  patients  sheep  skins  with 
the  wool  left  on,  procured  from  furriers,  who  often  sew  such  skins 
together  and  dye  them,  to  sell  as  fur  robes.  These  should  be  spread 
on  the  bed,  and  with  a  sheet  over  them  they  make  a  soft,  yielding 
support  which  retains  its  elasticity  indefinitely.  Similarly,  a  musk- 
ox  fur  robe  so  used  afforded  the  utmost  comfort  to  a  patient  wasting 
away  with  internal  cancer.  Where  such  articles  cannot  be  readily 
obtained,  the  patient  may  be  padded  where  necessary,  especially 
between  the  condyles  of  the  knees  or  at  the  scapula  and  sacrum, 
by  layers  of  cotton  batting,  frequently  changed  or  adjusted. 

With  the  disappearance  of  fat,  it  will  soon  be  noted  that  the 
muscles  are  losing  bulk  also.  This  muscular  atrophy  may  be  so 
marked  that  on  lifting  the  arm,  in  a  case  of  advanced  phthisis,  the 
large,  rounded  muscles  of  a  mechanic  may  seem  changed  into  the 
semblance  of  slender  cords  or  fiat  ribbons.     This  change  is  the  direct 


THE   SIGNIFICANCE    OF    EMACIATION  45 

result  of  the  febrile  processes  which  figure  among  the  commonest 
results  of  infections.  As  the  muscular  tissues  are  the  chief  generators 
of  animal  heat,  so  fever  is  a  muscular  disorder,  and  enfeeblement 
of  muscular  function  is  its  most  invariable  attendant.  Hence  what 
is  apparent  to  the  eye  in  the  external  muscles  must  coexist  in  all  mus- 
cular structures  within,  and  all  the  serious  complications  which  that 
fact  imphes  should  be  borne  in  mind.  Thus,  many  of  the  gravest  con- 
ditions in  typhoid  fever  are  due  to  a  virtually  emaciated  heart,  and 
as  we  shall  mention  in  discussing  the  treatment  of  that  disease, 
instead  of  trusting  to  cardiac  stimulants,  the  means  for  preventing 
emaciation  should  be  regarded  as  the  surest  resources  against  heart 
failure. 

The  same  holds  true  of  many  other  dangers  of  prolonged  fevers. 
In  tubular  structures  with  muscular  coats,  venous  congestion  and 
loss  of  muscular  tone  go  together.  Hypostatic  pneumonia  depends 
upon  filling  up  of  the  bronchi.  The  muscular  walls  of  the  stomach  and 
bowels  relax  with  gaseous  distention,  the  bladder  has  to  be  emptied 
with  a  catheter,  and  involuntary  discharges  occur  from  the  bowels, 
all  chiefly  effects  of  the  same  wasting  and  weakness  illustrated  by  the 
condition  of  the  heart.  Hence  one  of  the  most  important  questions  in 
the  treatment  of  wasting  fevers  is  how  to  feed  the  patient  so  as  to 
prevent  emaciation. 

Some  febrile  infections,  such  as  pneumonia  or  diphtheria,  run  too 
short  a  course  for  the  loss  of  fat  to  be  noticeable,  though  the  heart 
may  have  been  fatally  weakened.  It  is  in  chronic  infections,  how- 
ever, that  the  signs  of  emaciation  may  be  of  great  significance  for 
diagnosis.  In  them  the  bones  may  become  thinned  in  a  very  charac- 
tersitic  way,  as  may  be  noted  in  the  dread  insidious  infection  of  tuber- 
culosis. Long  before  any  physical  signs  are  discoverable  in  the  lungs 
the  tuberculosis  skeleton,  so  to  speak,  may  be  recognized.  A  recent 
pleural  effusion  is  ominous  if  the  shafts  of  the  radius  and  ulna  are  much 
too  slender.  So  perfectly  characteristic  is  the  contrast  between  the 
chests  of  two  patients  with  a  chronic  cough,  the  one  due  to  phthisis 
and  the  other  to  chronic  bronchitis,  that  the  diagnostic  value  of 
emaciation  thus  illustrated  warrants  a  detail  of  those  contrasts. 

A  glance  at  their  bones  and  muscles  suffices  to  show  that  these 
patients  are  suffering  from  conditions  of  disease  entirely  different  in 
nature,  although  both  have  dyspnea,  cough,  and  profuse  expectoration. 

In  chronic  bronchitis  the  thorax  is  large,  rounded,  and  distended, 
with  the  clavicles  raised;  in  phthisis,  the  chest  is  small  and  retracted 
and  the  clavicle  sunken.     The  neck,  therefore,  differs  in  every  respect, 


46  CLINICAL  MEDICINE 

being  short  and  thick  in  bronchitis,  with  the  chin  drawn  back,  while  in 
phthisis  it  is  long  and  slender,  with  the  chin  carried  so  far  forward  that 
a  vertical  line  from  it  would  drop  outside  the  umbihcus.  In  bronchitis 
the  accessory  muscles  of  respiration  are  wide  and  h3^pertrophied,  caus- 
ing the  supraclavicular  fossae  to  be  much  deepened;  in  phthisis  the 
neck  muscles  are  flat  and  attenuated  and  the  foss£e  shallow  or  obliter- 
ated. In  bronchitis  the  ribs  are  large  and  broad;  in  phthisis,  small 
and  narrow.  In  bronchitis  the  face  is  turgid,  the  ears  thick,  the  eye- 
lids swollen,  and  the  conjunctivae  suffused.  In  phthisis  the  ears  are 
thin  and  translucent,  the  cheeks  retracted,  with  a  characteristic  drawn 
appearance  from  the  platysma  myoides  being  put  on  the  stretch  by 
the  descent  of  the  clavicles,  while  the  conjunctivae  are  so  transparent 
that  the  eyeballs  look  glassy.  All  these  features  of  emaciation  in 
tuberculosis  are  serviceable  for  diagnosis  when  they  sometimes  long 
precede  any  notable  change  in  the  lungs.  Latent  tuberculosis  is  not 
uncommon,  and  should  be  suspected  if  the  bones  are  emaciated. 

Malignant  diseases,  whether  carcinoma  or  sarcoma,  but  especially 
carcinoma,  specifically  cause  emaciation  irrespective  of  their  seat. 
They  naturally  do  so  when  they  interfere  directly  with  ahmentation, 
as  in  cancerous  stricture  of  the  esophagus,  but  one  of  the  extremest 
cases  of  emaciation  which  I  remember  was  in  a  man  whose  normal 
weight  was  190  pounds,  but  who  at  autopsy  showed  only  a  small 
cancerous  tumor  involving  a  sacral  nerve,  and  a  few  enlarged  lymph- 
glands  with  small  scattered  deposits  in  the  Hver,  but  all  of  the  growths 
together  hardly  weighed  2  oz.  Gastric  cancer  was  regarded  as  par- 
ticularly wasting  because  of  the  accompanying  loss  of  peptic  power 
from  absence  of  free  hydrochloric  acid  in  the  stomach  secretion.  It 
is  now  shown  that  free  hydrochloric  acid  is  equally  absent  from  the 
gastric  juice  wherever  the  cancer  is  located,  as  in  mammary  or  uterine 
cancer,  so  that  this  deficiency  must  be  due  to  some  general  and  pro- 
found change  in  the  blood.  From  chnical  facts  we  must  conclude  that 
cancerous  growths  continuously  add  virulent  poisons  to  the  blood 
from  the  time  that  they  begin,  the  rule  being  that  the  slower  the 
growth,  the  greater  the  emaciation,  probably  due  to  the  bone-marrow 
becoming  affected  so  that  the  blood-cells  are  greatly  lessened  in  num- 
ber and  altered  in  shape,  while  the  general  metabolism  also  suffers  as 
shown  by  the  remarkable  diminution  of  urea  excreted  by  the  kidneys. 
The  patients,  therefore,  often  early  lose  flesh  and  color  much  before 
any  local  development  can  be  found,  while  the  constitutional  change  is 
accompanied  by  a  dinginess  of  the  skin  characteristic  of  the  cancerous 
cachexia.     Not  infrequently,  however,  we  have  to  make  a  provisional 


THE    SIGNIFICANCE    OF    EMACIATION  47 

diagnosis  of  hidden  malignant  disease  chiefly  because  the  emaciation 
cannot  be  accounted  for  otherwise. 

Gastro-intestinal  Disorders. — Some  disorders  of  the  gastro-intes- 
tinal  tract  are  accompanied  by  emaciation  and  others  are  not,  so  that 
this  symptom  should  be  taken  account  of  in  differential  diagnosis.  The 
diseases  of  the  stomach  which  cause  emaciation  may  be  either  organic 
or  functional.  Of  the  organic  affections,  chronic  gastric  ulcer  ac- 
companied by  pain  and  then  by  vomiting  soon  after  eating  may 
induce  extreme  wasting  because  the  meal  is  rejected  before  it  can 
become  food.  The  aspect  of  the  face  in  such  cases  is  quite  different 
from  febrile  emaciation,  for  there  is  no  flush  or  injection  of  the  skin, 
which  instead  is  blanched  with  the  temporal  veins  looking  very  blue 
by  contrast  on  the  white  surface.  This  serves  also  to  distinguish  the 
condition  from  gastric  cancer,  in  which  the  complexion  is  more  opaque. 
Meantime  the  cheeks,  instead  of  the  drawn  appearance  in  phthisis, 
are  sunken  in  between  the  jaws,  and  the  face  frequently  wears  the  ex- 
pression of  pain.  Chronic  gastritis  without  ulcer  causes  emaciation 
in  some  persons  when,  owing  to  loss  of  appetite  and  discomfort  or  pain 
after  eating,  they  tend  to  eat  so  little  that  they  become  in  time  \ar- 
tually  starved.  The  same  occurs  in  chronic  gastritis  after  the  gastric 
mucosa  becomes  so  atrophied  that  both  free  and  combined  free  HCl 
and  pepsin  and  rennin  are  absent.  This  condition  is  particularly 
characterized  by  lancinating  pains,  and  is  further  aggravated  if  the 
inflammatory  process  extends  to  the  duodenum. 

If  the  motor  function  of  the  stomach  walls  be  impeded,  the  food 
may  long  remain  in  the  stomach  undigested,  for  in  all  cases  of  loss 
of  motor  power  gastric  secretion  is  seriously  disturbed  or  ceases 
absolutely,  when,  from  want  of  the  antiseptic  properties  of  the  normal 
gastric  juice,  the  stomach  contents  decompose  and  are  finally  vomited. 
The  general  nutrition  often  suffers  in  these  patients.  On  the  other 
hand,  if  the  motor  function  remains,  so  that  the  gastric  contents 
are  discharged  into  the  intestine,  emaciation  may  not  occur,  for  many 
cases  of  total  absence  of  gastric  secretions  have  been  reported  in  pa- 
tients whose  body-weight  has  continued  normal  and  their  general 
health  unimpaired  because  the  intestinal  digestion  of  the  food  may  fully 
suffice  (Hemmeter). 

Functional  disorders  of  the  stomach  which  may  cause  emaciation 
are  of  nervous  origin,  as  in  those  cases  where  there  is  total  abolition  of 
the  nervous  function  of  appetite  along  with  persistent  repugnance  to 
food.  Ordinary  anorexia  is  of  httle  account,  as  people  usually  manage 
to  take  enough  food  even  when  they  do  not  crave  it,  but  the  anorexia 


48  CLINICAL  MEDICINE 

which  leads  to  starvation  is  always  an  accompaniment  of  some  serious 
neurosis.  One  curious  form  was  named  "anorexia  nervosa"  by  Sir 
William  Gall,  and  his  clinical  description  of  the  affection  I  can  fully 
confirm  from  my  own  experience.  The  patients  are  usually  girls,  who, 
after  a  varying  period  characterized  by  changes  in  or  perversity  of 
disposition,  begin  to  manifest  an  obstinate  aversion  to  food  in  any  form, 
and  continue  to  do  so  though  threatened  with  utter  starvation.  Mean- 
time they  seem  impelled  constantly  to  move  about  and  wear  out  their 
friends  with  the  long  walks  which  they  insist  on  taking.  Forced  rest 
in  bed  and  judicious  feeding  generally  work  a  cure.  Dangerous  ano- 
rexia is  also  frequent  in  insanity,  particularly  in  mania  and  in  melan- 
choHa,  so  as  to  require  forced  feeding,  but  even  this  measure  sometimes 
fails  to  arrest  the  rapid  emaciation  in  acute  cases. 

A  chronic,  though  not  extreme  form,  of  emaciation  is  worthy  of 
mention  because  its  cause  is  often  not  recognized.  A  very  persistent 
and  disabhng  anorexia  occurs  in  women  who  have  suffered  from 
pelvic  cellulitis,  on  account  of  the  chronic  irritation  analogous  to  the 
reflex  effects  of  pregnancy  on  the  stomach  and  duodenum  which  is 
set  up  by  old  inflammatory  exudations  in  those  regions.  It  is  remark- 
able how  Httle  nourishing  food  such  patients  eat  in  the  course  of  the 
day.  To  such  patients,  acids,  bitters,  and  other  drugs,  supposed  to 
improve  the  appetite  and  to  aid  digestion,  are  often  given  in  long 
succession  without  avail.  Proper  local  treatment  to  remove  the 
cause,  with  prolonged  stay  in  the  open  air  without  exercise,  as  in  a 
hammock,  are  more  successful  than  drugs  to  restore  appetite  and 
nutrition. 

Frequent  or  daily  vomiting  occurs  in  hysteria,  but  often  without 
any  accompanying  emaciation,  the  explanation  being  that  is  is  not 
food  which  is  then  ejected,  but  only  fluids  with  small  quantities  of 
mucus. 

A  persistent  gastric  disturbance  with  recurrent  attacks  of  green- 
ish vomiting  and  progressive  emaciation  should  always  lead  to  exami- 
nation of  the  urine  for  kidney  disease.  Emaciation  from  this  cause 
often  shows  no  signs  of  edema  even  in  the  face.  The  urine  may  con- 
tain but  Httle  albumin  and  not  many  casts,  but  the  percentage  of  urea 
will  be  found  continuously  low. 

Affections  of  the  bowels  producing  loose  or  frequent  movements 
vary  a  good  deal  in  their  proneness  to  cause  emaciation  according  to  the 
part  of  the  intestine  involved.  Though  modern  writers  seem  dis- 
posed to  deny  the  restriction  of  such  affections  to  separate  divisions 
of  the  intestinal  tract,  yet  there  are  chnical  differences  between  a 


THE   SIGNIFICANCE   OF   EMACIATION  49 

chronic  enteritis  and  a  chronic  coHtis  which  still  justify  the  use  of  the 
terms  "diarrhea"  and  "dysentery."  In  chronic  diarrhea  the  commonest 
time  of  onset  is  the  latter  part  of  the  night  or  early  morning,  when  the 
patient  has  been  resting  quietly  without  taking  food  for  hours.  In 
dysentery  the  taking  of  a  meal  induces  at  once  a  desire  for  stool,  and  so 
does  bodily  exertion.  In  dysentery  the  pylorus  seems  to  remain  re- 
laxed, and  the  food  not  only  passes  quickly  through  the  stomach,  but 
the  peristalsis  of  the  bowels  started  by  that  of  the  stomach  is  so  active 
that  patients  may  tell  you  that  they  can  often  detect  in  the  dejecta 
the  smell  of  the  articles  of  food  on  which  they  had  just  dined.  This 
never  occurs  in  diarrhea.  The  worst  results  as  far  as  emaciation  is 
concerned  may  be  noted  in  the  dysentery  of  infants.  The  smallest 
quantity  of  milk  swallowed  brings  on  a  movement  in  which  the  milk 
is  seen  to  have  passed  quite  undigested.  The  little  patients  thus  be- 
come so  starved  that  they  look  like  old  weazened  mannikins. 

The  explanation  of  this  difference  between  diarrhea  and  dysentery 
is  to  be  found  in  the  nervous  relations  between  the  stomach  and  the 
rectum.  In  health,  the  best  time  to  have  a  natural  evacuation  of  the 
bowels  is  after  the  meal  which  has  been  taken  when  the  stomach  has 
been  longest  empty,  that  is,  in  the  morning.  The  rectum  is  in  such 
reflex  association  with  the  stomach  that  it  is  excited  to  expel  its  con- 
tents as  soon  as  fresh  food  enters  above.  But,  conversely,  irritation 
of  the  rectum  reacts  upon  the  stomach  to  empty  its  contents  by  relax- 
ing the  pylorus,  and  when  this  irritation  is  persistent,  as  in  dysentery, 
the  effects  are  as  just  mentioned.  Washing  out  the  rectum  with  quite 
warm  but  not  too  hot  water,  with  a  little  peppermint,  after  each  move- 
ment, and  then  potassium  bromid  in  a  small  enema,  are  each  measures 
which  allay  this  reflex  irritation,  while  the  food  given  should  be  admin- 
istered in  as  small  bulk  as  possible.  It  is  in  these  cases  that  scraped 
raw  meat  taken  in  ^  to  i  teaspoonful  doses,  is  so  curative,  both 
of  the  dysentery,  by  allowing  rest  to  the  inflamed  bowel,  and  of  the 
emaciation,  by  allowing  the  ahment  to  stay  long  enough  to  be  taken  up. 
Milk,  while  eminently  adapted  for  the  treatment  of  most  cases  of 
diarrhea  if  properly  prepared,  is,  nevertheless,  both  bulky  and  slow 
of  digestion,  and  hence  is  contra-indicated  in  the  treatment  of  dysen- 
tery, acute  or  chronic. 

On  the  other  hand,  it  is  surprising  how  many  years  chronic  di- 
arrhea may  continue  with  some  patients  without  their  losing  flesh. 
Whenever,  therefore,  emaciation  does  accompany  diarrhea  we  have 
reason  to  suspect  some  constitutional  cause,  as  tuberculosis  or  Graves' 
disease. 

4 


50  CLINICAL  MEDICINE 

Many  cases  of  cirrhosis  of  the  liver  exhibit  a  wasting  of  the  mus- 
cular tissues  which  cannot  be  ascribed  exclusively  to  disordered  diges- 
tion from  portal  obstruction.  The  skin  also  in  them  shows  character- 
istic changes.  It  is  both  rough  and  dry,  and  can  be  Hfted  in  such  leath- 
ery folds  that  I  have  diagnosed  hepatic  cirrhosis  from  this  symptom 
when  there  was  no  ascites.  The  face  may  show  emaciation  in  the 
sunken  eyes  and  cheeks,  and,  besides  having  an  opaque  and  rather 
sallow  tint,  there  are  to  be  found  characteristic  areas  of  dilated  venules 
on  the  nose  and  cheeks.  These  patients  often  seem  to  die  from  pure 
muscular  debility. 

In  most  cases  of  obstructive  jaundice  loss  of  fat  occurs  early,  and  this 
appears  to  be  mainly  due  to  imperfect  emulsification  of  food  fats  in 
the  intestine  from  deficiency  of  bile,  as  the  addition  of  bile  greatly 
increases  the  activity  of  the  fat-splitting  ferment  in  the  pancreatic 
juice.  If,  however,  jaundice  continues,  actual  emaciation  occurs,  the 
general  nutrition  apparently  suffering  from  the  toxic  influence  of  bile 
in  the  tissues. 

In  diabetes  mellitus  emaciation  always  occurs,  though  in  the  class 
who  from  the  beginning  are  very  fleshy  it  may  not  be  so  obvious  at 
death,  owing  to  the  curious  fact  that  in  diabetes  other  tissues  waste 
faster  than  the  fat  does.  In  the  young  and  in  adults  who  have  never 
been  obese  the  emaciation  is  often  extreme,  its  progress  being  pro- 
gressive from  the  time  that  sugar  is  generated  directly  out  of  the  pro- 
tein elements  of  the  body  independently  of  the  hydrocarbons  of  food. 
I  have,  therefore,  long  reUed,  in  the  prognosis  of  diabetes,  upon  the 
amount  of  excess  of  urea,  as  well  as  upon  the  amount  of  sugar 
excreted. 

Graves'  disease,  misnamed  ''exophthalmic  goiter,"  because  many 
cases  occur  and  progress  even  to  a  fatal  issue  without  either  exoph- 
thalmos or  goiter,  often  causes  such  extreme  emaciation  that  the 
patients  have  all  the  appearances  of  advanced  phthisis.  In  some  it 
appears  as  an  early  symptom,  while  in  others  emaciation  does  not 
become  pronounced  until  diarrhea  sets  in.  I  regard  Graves'  disease 
as  due  primarily  to  an  auto-infection  with  a  poison  generated  in  the 
intestine  which  paralyzes  the  vasoconstrictors  the  body  over,  and 
which  may  or  may  not  involve  the  thyroid  gland.  (Consult  the 
author's  "Graves'  Disease,  With  and  Without  Exophthalmic  Goiter," 
Wm.  Wood  &  Co.,  New  York,  1904.)  This  ptomain  seems  to  be  gen- 
erated from  nitrogenous  elements  in  the  blood,  causing  butcher  meat 
to  be  as  poisonous  to  those  patients  as  starch  or  sugar  are  to  diabetics. 
At  any  rate,  a  proper  diet  is  the  best  remedy,  both  for  the  disease  and 


COUGH  5 1 

for  the  emaciation  consequent  upon  it.  In  any  patient,  therefore, 
who  is  plainly  emaciated  without  any  cause  being  discoverable,  the 
diagnosis  of  Graves'  disease  becomes  quite  certain  if,  with  the  char- 
acteristic persistent  tachycardia,  the  other  nervous  and  secretory 
derangements  of  this  pecuHar  complaint  are  present,  though  there  be 
no  exophthalmos  or  goiter. 

COUGH 

Cough  is  a  reflex  act  whose  afferent  excitation  may  come  from 
quite  a  variety  of  sources  or  locahties.  All  coughs,  however,  may  be 
sharply  divided  into  two  classes:  first,  the  expectorant  cough;  second, 
the  irritant  cough. 

The  expectorant  cough  is  of  only  one  kind,  and  virtually  has  but 
one  cause,  namely,  something  to  be  expectorated.  The  irritant 
cough,  on  the  other  hand,  is  not  due  to  anything  which  may  be  got 
rid  of  by  coughing,  and  hence  is  always  useless,  if  not  harmful.  This 
cough  is  of  many  kinds,  according  to  the  locahty  of  the  irritation.  It 
has  no  less  than  twelve  varieties,  as  follows: 

1.  Direct  irritation,  usually  inflammatory,  of  the  sensory  nerves 

of  the  mucous  membrane  of  the  air-passages  from  the  pharynx 
and  larynx  down,  without  the  presence  of  fluid  secretions. 

2.  Irritation  of  the  pleura. 

3.  Irritation  of  the  under  surface  of  the  diaphragm. 

4.  Valvular  disease  of  the  heart. 

5.  From  the  infection  of  pertussis. 

6.  Irritation  of  the  external  meatus  of  the  ear. 

7.  Aneurysmal  cough. 

8.  Irritation  of  the  stomach. 

9.  Irritation  of  the  intestine. 

10.  Irritation  of  the  cervix  uteri. 

11.  Hysteric  cough. 

12.  Basilar  meningitis. 

The  practical  advantage  of  this  classification  is  that  the  expecto- 
rant cough  is  the  only  cough  which  effects  a  good  purpose,  and  there- 
fore should  be  aided  and  not  suppressed.  All  irritant  coughs  serve  no 
good  purpose,  and  the  aim  should  be  to  suppress  them.  It  is  of  much 
practical  advantage,  therefore,  to  the  physician  that  he  should  learn 
how  to  distinguish  the  expectorant  cough  from  the  irritant  cough  at 
once.  This  can  be  done  by  paying  attention  to  the  sound  of  the  cough, 
for  the  expectorant  and  the  irritant  coughs  are  quite  different  in  their 
sound.     It  matters  not  to  which  of  the  many  kinds  of  irritant  coughs 


52  CLINICAL  MEDICINE 

he  may  be  listening,  the  cough  itself  has  one  and  the  same  character, 
while  it  may  likewise  be  said  of  the  expectorant  cough  that  it  does  not 
vary  in  its  distinctive  sound  either,  so  that  although  both  may  be 
occurring  together,  yet  the  one  can  always  be  distinguished  by  the 
sound  from  the  other.  Thus,  the  sounds  accompanying  an  expectorant 
cough  are  invariably  linked  together,  each  cough  being  joined  to  the 
preceding  and  to  the  subsequent  cough,  so  that  its  sound  may  be 
likened  to  that  of  a  chain  running  over  a  pulley.  This  cough,  which 
once  begun  can  be  checked  only  with  difficulty,  ends  with  the  charac- 
teristic sound  of  expectoration  into  the  pharynx.  The  sounds  of  the 
irritant  cough,  on  the  other  hand,  are  always  independent  of  each  other, 
and  may  be  Ukened  to  the  separate  blows  of  a  hammer,  and,  whether 
few  or  numerous,  they  are  not  linked  together.  The  term  dry  is  ap- 
pHed  to  this  cough^to  denote  the  absence  of  all  sounds  of  fluid  connected 
with  it. 

For  the  sake  of  convenience  we  will  first  review  the  different  vari- 
eties of  the  irritant  cough: 

1.  From  the  experiments  of  Kohts,  irritation  of  the  under  surface 
of  the  vocal  chords  in  the  larynx  produces  the  most  violent  cough, 
sufficient,  if  the  irritation  is  continued,  to  cause  general  convulsions. 
Irritation  of  the  trachea  produces  much  less  cough  until  the  mucous 
membrane  at  the  first  division  of  the  bronchi  is  reached,  when  the 
cough  is  much  more  violent.  The  membrane  between  that  place  and 
the  next  division  of  the  bronchi,  though  still  susceptible,  is  not  as 
excitable  as  at  the  second  division,  where  the  irritation  then  pro- 
duces severe  cough,  but  not  as  violent  as  at  the  first  division.  Simi- 
larly, the  membrane  at  the  third  division  is  more  susceptible  than  the 
parts  between.  This  susceptibility  progressively  decreases  until  it 
disappears  in  the  smallest  bronchi. 

2.  Kohts  found  that  either  mechanical  or  electric  irritation  of 
the  pleura  will  cause  an  irritant  or  dry  cough.  This  cough  may  be 
very  sHght  when  the  irritated  pleural  surface  is  moderate  in  extent, 
but  may  be  violent  in  proportion  to  the  area  of  the  surface  involved. 
An  example  of  the  first  kind  is  the  ominous  short,  hacking  cough  of 
incipient  phthisis.  Owing  to  the  excitability  of  the  cutaneous  nerves 
overlying  the  affected  pleura,  this  symptom  may  be  of  service  for 
diagnosis,  for  the  appHcation  of  the  cold  hand  there  will  excite  this 
cough  when  the  same  apphcation  would  not  over  the  apex  of  the  sound 
lung.  The  cough  at  the  commencement  of  acute  pleurisy  is  usually 
short,  owing  to  its  being  voluntarily  checked  by  the  patient  from  the 
pain  which  it  occasions.     When  fluid  accumulates  in  the  pleura  the 


COUGH  53 

cough  may  cease,  to  return  with  increased  violence  upon  the  absorp- 
tion of  the  effusion,  when  the  roughened  surfaces  of  the  pleura  rub 
together  again.  The  cause  of  this  severe  coughing  should  be  recognized 
at  once  by  its  characteristic  sound,  and  is  best  reUeved,  not  by  ano- 
dynes, but  by  firm  strapping  of  the  side.  A  similar  local  strapping 
often  mitigates  the  severe  cough  accompanying  a  cavity  in  a  phthisical 
lung,  as  the  walls  of  the  vomica  are  always  adherent  at  the  wall  of 
the  chest,  and  so  produce  constant  pleuritic  irritation. 

3.  When  inflammation  of  the  liver  extends  to  its  upper  surface,  so 
as  to  cause  perihepatitis,  it  excites  a  short,  hacking  cough  due  to 
irritation  of  the  sensory  nerves  of  the  under  surface  of  the  diaphragm. 

4.  Cough  occurs  in  valvular  disease  of  the  heart  most  commonly 
in  patients  with  mitral  stenosis.  This  is  due  to  pulmonary  stasis 
producing  congestion  of  the  mucous  membrane  of  the  bronchi.  In 
some  cases  of  extreme  pericardial  effusion  cough  is  produced  by  press- 
ure on  the  bronchi  or  upon  the  pneumogastric  nerves. 

5.  The  cough  of  pertussis,  though  at  first  very  similar  to  an  expec- 
torant cough,  is  due  to  a  specific  irritation  of  the  upper  air-passages, 
causing  a  rapid  spasmodic  cough  ending  with  the  characteristic  laryn- 
geal whoop,  until  it  terminates  in  an  expectorant  cough. 

6.  Irritation  of  the  external  meatus  of  the  ear  may  cause  violent 
coughing,  and  when  such  coughing  occurs  without  any  of  the  usual 
antecedents  of  cough  in  a  child  it  should  lead  to  an  examination  of  the 
ear,  when  it  may  be  found  to  be  caused  by  a  foreign  body,  such  as  a 
bean,  put  into  the  ear  by  the  child.  Sometimes  in  adults,  examining 
the  external  auditory  meatus  with  a  speculum  may  excite  cough. 
According  to  Dr.  Fox,  of  Philadelphia,  the  afferent  nerve  irritated  is 
the  auriculotemporal  branch  of  the  fifth  nerve.   i^U^s.-UaI^'^-^V  ^^'^l.-*'-^-! 

7.  The  cough  produced  by  a  thoracic  aneurysm  is  of  laryngeal 
origin  from  pressure  of  the  tumor  upon  the  recurrent  laryngeal  nerves, 
and  occurs  mostly  when  the  tumor  springs  from  the  transverse  arch. 
The  sound  of  the  cough  is  of  a  brazen,  ringing  character.  If  the 
tumor,  however,  presses  upon  the  windpipe  or  on  a  main  bronchus, 
the  cough  is  often  paroxysmal,  and  may  then  be  accompanied  by  ex- 
pectoration, with  stridor  on  inspiration.  It  is  important  to  add  that  a 
foreign  body  lodged  in  a  primary  bronchus  will  cause  the  same  sound- 
ing cough.  A  man  was  admitted  in  my  service  at  Bellevue  Hospital 
with  a  diagnosis,  made  by  three  physicians,  of  pneumonia.  His  tem- 
perature stood  at  105°  F.  As  soon  as  I  heard  him  cough  I  said  that 
this  pneumonia  must  be  due  to  plugging  of  a  primary  bronchus  by  a 
foreign  body.     The  right  bronchus  was  cut  down  upon,  at  my  direction, 


54  CLINICAL  MEDICINE 

and  a  piece  of  a  filbert  was  extracted,  which  the  man  had  inhaled  from 
his  mouth  while  in  a  state  of  intoxication  on  a  Christmas  night  revel. 

8.  The  presence  of  undigested  contents  in  the  stomach  may 
undoubtedly  cause  cough,  especially  in  children  during  the  night. 
This  stomach  cough  is  generally  believed  in  by  mothers  and  nurses, 
and  not  without  reason,  for  experimentally  it  has  been  shown  that 
irritation  of  the  different  branches  of  the  pneumogastric  will  occasion 
cough.  This  cough  is  dry  and  paroxysmal,  and  may  be  mistaken  for 
whooping-cough.  It  is  claimed  by  some  that  it  is  a  frequent  accom- 
paniment of  malarial  infection. 

9.  It  is  equally  certain  that  round  worms  present  in  the  intestine 
may  occasion  the  same  kind  of  cough ;  as  it  so  often  ceases  upon  expul- 
sion of  the  worms  such  causative  connection  with  the  cough  is  very 
probable. 

10.  Some  cases  of  prolonged  and  severe  paroxysmal  coughing  in 
women  are  due  to  irritation  of  the  cervix  uteri.  One  case  of  the  kind, 
which  had  tormented  the  patient  for  three  years,  was  found  by  me  to 
be  dependent  upon  a  large  polypus  protruding  from  the  external  os. 
On  the  removal  of  this  polypus  the  cough  soon  ceased. 

11.  Many  women  with  hysteria  have  a  loud,  barking  cough,  the 
genesis  of  which  is  obscure.  Other  signs  of  hysteria  are  always  more 
or  less  present  in  such  patients,  and  the  cough  is  best  treated  by  reme- 
dies directed  to  the  constitutional  condition. 

12.  Kohts  found  that  irritation  of  the  floor  of  the  fourth  ventricle, 
above  the  center  for  respiration,  excites  cough.  It  is  frequently 
present,  therefore,  in  tubercular  meningitis,  and  is  then  evidence  of 
the  basilar  situation  of  the  inflammation. 

The  expectorant  cough  has  for  its  purpose  to  get  rid  of  fluids  pres- 
ent in  the  air-passages.  Fluid,  as  such,  is  as  much  a  foreign  body  in 
the  air-tubes  as  any  other  substance.  All  that  should  be  present 
in  these  tubes  is  air,  with  the  mucous  membrane  of  their  walls  simply 
moistened  by  a  bland,  sHghtly  saline  secretion.  Now,  any  foreign 
body  occupying  the  lumen  of  a  bronchial  tube  must  be  quickly  removed 
or  the  worst  results  follow  in  the  air  vessels  beyond  the  obstruction. 
This  is  shown  in  the  special  form  of  pneumonia  which  occurs  in  the 
lung  whose  main  bronchus  has  been  plugged  by  a  solid  body  accident- 
ally entering  through  the  larynx,  as  in  the  case  above  mentioned.  The 
resulting  inflammation  is  worse  than  when  the  air  vesicles  become 
filled  with  the  exudate  of  croupous  pneumonia,  for  this  may  be  ab- 
sorbed with  Httle  damage  to  the  alveolar  walls,  but  in  the  inflammation 
excited  by  bronchiole  obstruction  the  tendency  is  to  a  disorganization 


COUGH 


55 


involving  both  the  walls  of  the  air-cells  and  the  interstitial  tissues  be- 
tween the  lobules.  Now,  plugs  of  viscid  mucus  which  cannot  be  dis- 
lodged from  the  bronchioles  are  just  as  operative  in  causing  lobular 
changes  as  any  other  kind  of  obstruction,  so  that  when  in  a  general 
bronchitis  the  temperature  begins  sharply  to  rise,  we  have  reason 
to  dread  the  supervention  of  that  mechanically  produced  broncho- 
pneumonia which  makes  a  bronchitis  dangerous.  Caseous  degenera- 
tion of  the  contents  of  such  lobules  prepares  the  way  for  tubercular 
infection,  so  that  patients  often  correctly  ascribe  the  beginning  of 
their  phthisis  to  a  cold  which  they  caught,  with  its  accompanying 
bronchitis. 

The  first  indication,  therefore,  in  the  treatment  of  expectorant 
coughs  is  to  make  the  secretion  as  fluid  as  possible.  In  bronchial 
hemorrhage,  for  example,  the  blood  is  brought  up  into  the  pharyTix  so 
readily  and  with  so  httle  cough  that  the  patients  think  that  it  comes 
from  the  stomach.  On  the  other  hand,  when  the  secretion  is  very 
viscid,  the  cough  on  that  account  may  be  violent  and  distressing,  be- 
cause there  is  no  stopping  it  until  it  ends  in  expectoration.  The 
tough  pellets  of  mucus  then,  Hke  other  foreign  bodies  in  the  air- tubes, 
set  up  reflex  spasms  of  the  bronchi,  causing  wheezing  rales,  as  well  as 
spasmodic  laryngeal  stenosis,  which  imparts  a  husky  or  squeaking 
sound  to  the  cough,  which,  on  that  account,  is  often  called  "tight."  A 
number  of  serious  results  follow,  not  primarily  from  bronchitis,  but 
from  viscid,  adherent  mucus.  Many  cases  of  chronic  bronchitic  asthma 
with  resulting  pulmonary  emphysema  are  thus  set  up  purely  by  the 
character  of  the  bronchial  secretion,  which,  if  dealt  with  in  time, 
might  have  been  wholly  prevented  by  remedies  calculated  to  make 
bronchial  secretion  simply  fluid,  as  will  be  mentioned  in  the  chapter 
on  Bronchitis. 

An  inflammatory  condition  of  the  air-passages,  however,  constantly 
excites  cough  of  the  irritant  kind,  independent  of  secretion  to  be  ex- 
pectorated. This  is  particularly  the  case  in  laryngitis,  when  the  sound 
of  the  cough  is  quite  characteristic,  being  of  a  brassy  or  ringing  char- 
acter from  spasm  of  the  vocal  chords,  when  it  is  also  accompanied  with 
stridor  on  inspiration.  But  the  same  inflammatory  irritation,  wherever 
situated  in  the  air-passages,  will  excite  cough,  so  that  in  most  patients 
with  bronchitis  we  have  much  useless  coughing,  which  aggravates  the 
existing  inflammation.  By  noting  the  accompanying  sounds  the 
physician  can  infer  how  much  of  the  cough  is  due  to  mucus  to  be  ex- 
pelled, and  how  much  is  only  irritant  and  occurring  between  the 
intervals  of  the  expectorating  cough.     If  the  secretion  becomes  more 


56  CLINICAL  MEDICINE 

liquid,  the  irritant  cough  becomes  less,  but  if  it  unduly  continues, 
the  indication  is  then  to  suppress  it  by  the  addition  of  anodynes  to 
the  expectorant  agents.  On  the  same  principle,  the  injurious  cough 
of  laryngitis  is  soothed  by  the  steam  of  boihng  water  and  syrup  led 
from  a  croup  kettle  under  a  tent  in  which  the  child  lies. 

A  different  condition  from  the  preceding  is  when  there  is  too  abun- 
dant watery  secretion.  This  occurs  especially  in  the  chronic  coughs  of 
old  people  with  weakened  and  dilated  right  ventricle  of  the  heart. 
This  fluid  bronchial  secretion  is  prone  to  collect  at  the  bases  of  both 
lungs,  and  its  expectoration  causes  much  trouble  to  these  debihtated 
patients,  especially  in  the  night.  The  indication  here  is  to  strengthen 
the  heart  walls  by  appropriate  remedies,  and  check  the  secretion  by 
mineral  acid  astringents,  especially  nitric  acid,  and  small  doses  of 

iodids. 

SIGNIFICANCE  OF  DYSPNEA 

Dyspnea,  or  difhcult  breathing,  may  be  of  threefold  origin,  pul- 
monary, cardiac,  and  hemic,  or  that  caused  by  conditions  of  the 
blood  itself. 

In  the  first,  or  pulmonary,  the  dyspnea  may  arise  from  disorder  irt 
the  lung,  or  in  its  appendages,  the  bronchi  or  the  pleura. 

The  lung  may  be  affected  by  inflammatory  exudation  into  its  air- 
vesicles,  as  in  croupous  pneumonia.  Usually,  however,  this  exuda- 
tion fills  up  but  a  portion  of  one  lung,  when  the  patient  may  have 
but  moderate  dyspnea  and  He  on  the  affected  side.  If  in  this  condi- 
tion he  shows  signs  of  dyspnea,  with  dusky  countenance  and  rapid 
breathing,  these  symptoms  are  those  of  toxic  origin.  The  respiratory 
region  of  the  face,  or  the  nostrils  and  upper  Hps,  will  then  give  their 
signs,  namely,  dilatation  of  the  nostril  corresponding  to  the  affected 
side,  with  the  mouth  sHghtly  opened.  When  both  lungs  are  affected 
the  signs  of  dyspnea  are  usually  more  pronounced,  but  are  still  not  so 
evident  as  in  other  cases  of  difficult  breathing. 

Urgent  dyspnea  may  also  supervene  when  air  suddenly  accumulates 
in  one  pleural  cavity.  I  was  once  called  in  consultation  by  two 
physicians  to  see  a  case  of  pneumonia.  I  found  no  pneumonia,  but 
instead  a  total  absence  of  respiratory  sounds  with  general  resonance  on 
percussion  over  the  whole  of  the  left  lung.  The  explanation  was  that 
the  patient  had  a  small  area  of  tuberculous  infiltration  at  the  apex, 
which  had  softened,  but,  instead  of  the  pleura  adhering  as  usual  at 
that  spot  to  the  rib,  it  left  a  small  hole  which  allowed  the  inspired  air  to 
pass  into  the  pleural  cavity  until  the  lung  itself  collapsed  from  pneumo- 
thorax, while  the  suddenness  of  the  accident  caused  the  great  dyspnea. 


SIGNIFICANCE   OF   DYSPNEA  57 

The  opposite  conditions  of  the  air-vesicles,  when  instead  of  being 
filled  with  exudation  they  are  overdistended  with  air,  causes  very- 
pronounced  dyspnea.  This,  however,  is  an  emphysematous  condition, 
as  it  is  consecutive  to  chronic  bronchitis  or  asthma.  The  respira- 
tory movements  of  the  chest  walls  are  then  much  restricted  and  may 
be  simply  up  and  down.     Both  nostrils  are  also  distended. 

Affections  of  the  bronchi  are  frequent  causes  of  dyspnea.  This  may 
be  of  purely  nervous  origin,  as  in  asthma.  Being  bilateral  in  charac- 
ter, the  patient  cannot  lie  down.  Auscultation  quickly  reveals  why 
the  breathing  is  difficult,  for  the  air  cannot  come  out  freely  from  the 
lung,  but  is  delayed  in  expiration  by  bronchial  spasm,  which  causes 
whistling  or  wheezing  sounds  over  both  lungs. 

Urgent  dyspnea  may  be  caused  by  inflammation  with  spasms  and 
exudation  in  the  larynx,^as  in  membranous  croup.  In  bad  cases  the 
lower  ribs,  instead  of  expanding  with  inspiration,  fall  in. 

Narrowing  the  chink  of  the  glottis  may  also  cause  dyspnea  from 
spasm  of  the  vocal  chords  by  the  presence  of  an  aneurysm  pressing 
upon  the  recurrent  laryngeal  nerve.  In  all  these  cases  of  laryngeal  ob- 
struction the  accompanying  cough  is  brassy  in  character,  as  it  is  also 
when  a  main  bronchus  is  plugged  by  a  foreign  body. 

Bronchitis  does  not  cause  dyspnea  so  long  as  the  main  bronchi 
only  are  involved,  but  when  the  inflammation  extends  below  the  third 
division  of  the  air-tubes  the  breathing  becomes  labored.  Orthopnea, 
or  being  obliged  to  sit  up  for  breathing,  then  sets  in. 

Fluid  effusions  into  the  pleura  on  one  side,  if  gradual  in  their 
production,  may  cause  no  dyspnea.  The  patient  may  then  go  about 
for  days  without  knowing  that  he  had  serious  trouble,  except  that  he 
finds  he  is  short  of  breath.  The  nostril  on  the  affected  side,  however, 
will  be  widely  dilated.  When  pleural  effusion  occurs  rapidly  on  both 
sides  the  dyspnea  is  extreme. 

Cardiac  dyspnea  may  be  due  to  conditions  in  the  heart  itself,  or 
in  its  appendages,  the  blood-vessels  and  the  pericardium. 

Pericarditis  with  effusion  may  cause  great  difficulty  in  breathing 
when  the  effusion  is  so  great  as  to  embarrass  the  heart  in  its  move- 
ments. The  most  frightful  dyspnea,  however,  occurs  as  a  result  of 
peripericarditis,  when  the  inflammation  of  the  pericardium  extends 
outside  that  structure  and  attaches  it  to  the  sternum  and  to  the 
adjacent  ribs.  These  external  adhesions  prevent  the  heart  itself  from 
contracting,  so  that  it  becomes  much  dilated  and  not  capable  of  com- 
pletely emptying  its  cavities.  Nothing  but  tightly  strapping  the 
lower  left  ribs  gives  any  relief,  and  that,  at  best,  is  but  temporary. 


58  CLINICAL   MEDICINE 

Owing  to  the  importance  of  early  recognition  of  the  condition,  we 
would  allude  first  to  difficult  breathing  due  to  the  state  of  the  arteries. 
Many  persons  after  middle  life  begin  to  notice  that  they  cannot 
walk  as  fast  as  before,  or  that  they  soon  get  out  of  breath  going  up- 
stairs or  in  walking  against  the  wind.  Otherwise  they  feel  quite  well. 
But  this  incipient  dyspnea  is  the  first  sign  of  beginning  arteriosclerosis 
with  its  long  train  of  evils,  whose  nature  and  prophylaxis  we  shall 
discuss  at  length  hereafter. 

Degeneration  of  the  myocardium  of  the  heart  wall  itself  so  that  it 
is  not  equal  to  carry  on  the  circulation  may  cause  intense  dyspnea, 
though  there  may  be  no  valvular  obstruction.  The  signs,  then,  are 
absence  of  palpable  beat  of  the  heart  externally,  along  with  a  very  in- 
termittent pulse,  often  accompanied  by  dropsical  swelling  of  the  legs. 
The  patient  cannot  lie  down  and  has  to  sleep  sitting  up  in  a  chair. 
This  dyspnea  rapidly  subsides  with  free  dosing  of  digitahs,  squills,  and 
permanently  by  iron  and  open-air  breathing,  the  best  sign  of  improve- 
ment being  that  the  pulse  no  longer  intermits. 

Conditions  of  the  blood  itself  rarely  cause  dyspnea.  Great  im- 
poverishment of  the  red  corpuscles,  as  in  pernicious  anemia,  will 
frequently  cause  rapid  breathing,  but  no  real  difficulty  in  breathing. 
There  is  one  form,  however,  fortunately  quite  uncommon,  in  which 
fatal  dyspnea  of  the  most  aggravated  character  occurs  from  the 
formation  in  the  blood  of  a  multitude  of  small  emboli  of  fat  which 
plug  up  the  pulmonary  capillaries.  This  occurs  in  that  mysterious 
disease  diabetes  mellitus,  but  why,  is  as  unknown  as  many  other 
problems  in  that  disease. 

Dyspnea  caused  by  valvular  disease  of  the  heart  occurs  most 
commonly  in  cases  of  mitral  stenosis  when  the  lungs  become  engorged 
through  inability  to  drive  the  blood  through  the  narrowed  mitral  valve. 
Mitral  regurgitation,  on  the  other  hand,  may  persist  for  years  without 
causing  dyspnea,  until  its  terminal  effects  are  seen  in  widespread  venous 
engorgements  with  dropsical  effusion  which  bring  on  difficult  breath- 
ing. Orthopnea,  or  having  to  sit  up  to  breathe,  should  always  attract 
attention,  for  it  means  that  both  lungs  are  involved  in  the  difficulty 
of  breathing,  and,  of  course,  this  occurs  oftener  in  cardiac  than  in  any 
other  disorders. 

SIGNIFICANCE  OF  EDEMA 

While  the  presence  of  edema  is  one  of  the  most  easily  recognizable 
of  morbid  conditions,  pathologists  find  its  mechanism  quite  diificult 
to  explain.     Thus,  many  suppose  that  whatever  arrests  the  return 


SIGNIFICANCE    OF    EDEMA  59 

current  through  the  veins  and  lymphatics  will  cause  a  watery  leakage 
from  these  vessels  into  the  tissues  of  the  part.  The  dropsy  from  heart 
disease,  and  abdominal  dropsy  or  ascites  from  venous  obstructions  in 
the  liver  are  regarded  as  sufficient  illustrations  of  this  principle.  But 
there  is  no  dropsy  more  general  or  complete  than  in  some  forms  of 
kidney  disease.  But  where  is  venous  or  lymphatic  obstruction  in 
them?  Again,  if  it  be  disorganization  of  the  kidney  structures  which 
causes  universal  dropsy,  why  do  so  many  cases  of  wasted  and  chron- 
ically ruined  kidneys  in  chronic  interstitial  nephritis  never  show  a 
sign  of  dropsy  anywhere?  Again,  what  is  the  relation  of  edema  in 
general  to  inflammatory  effusions?  Is  the  great  accumulation  of 
fluid  in  the  pleura  or  pericardium  in  inflammation  of  those  serous  sacs 
wholly  different  in  its  etiology  from  dropsy  in  the  peritoneal  sac  accom- 
panying cirrhosis  of  the  Hver?  Or,  again,  how  does  edema  of  the  lungs 
with  no  edema  elsewhere  sometimes  occur  so  suddenly  in  Bright's 
disease? 

These  questions,  suggested  by  bedside  experience,  show  that  the 
subject  of  edema  is,  to  say  the  least,  extremely  complex,  and  ere  long 
its  study  will  be  found  to  involve  the  question  of  the  mechanism  of 
absorption  as  well.  Now,  it  happens  that  the  physiology  of  absorption 
is  equally  a  subject  of  very  diverse  interpretation  among  investigators, 
according  to  their  physical,  clinical,  dynamic,  or  vital  cellular  explana- 
tions. Against  the  mere  mechanical  theory  of  dropsy,  that  it  comes 
from  overdistention  of  obstructed  blood-vessels,  are  such  facts  that 
Hgature  of  the  femoral  vein  in  a  healthy  man  may  have  no  effect  what- 
ever on  his  leg,  and  in  the  experimental  laboratory  it  is  found  that  even 
ligation  of  the  lower  end  of  the  inferior  vena  cava  in  dogs  produces  no 
edema  of  the  legs. 

Also,  if  we  produce  an  artificial  plethora  and  overfill  the  blood- 
vessels by  injecting  large  quantities  of  normal  sahne  solution  into  the 
circulation,  we  still  fail  to  produce  any  dropsy. 

As  an  illustration  of  the  wholly  unsettled  state  of  opinion  on  the 
main  principles  underlying  this  subject,  we  would  briefly  advert  to 
two  of  the  most  recent  observations  regarding  it.  Professor  E.  B. 
Starhng,  of  Guy's  Hospital,  says  that  everything  seems  expHcable 
on  the  purely  physical  principle  of  diffusion,  filtration  and  osmosis; 
but  Professor  E.  Weymouth  Reid,  in  Schafer's  "Text-Book  of  Physi- 
ology," says  that  when  we  come  to  the  living  body  it  is  rare  to  iind  in  it 
the  conditions  present  for  a  free  diffusion  between  the  constituents  of 
two  solutions.  If  a  pig's  bladder  separates  methyl  alcohol  and  ether, 
the  methyl  alcohol  diffuses  into  the  ether,  but  if  a  caoutchouc  mem- 


6o  CLINICAL  MEDICINE 

brane  separates  the  two  solutions,  the  ether  diffuses  into  the  alcohol. 
He  goes  on  to  say,  "It  must  be  admitted  that  in  spite  of  the  great 
labor  that  has  been  expended  on  the  determination  of  endosmotic 
equivalents  on  different  substances  with  different  membranes,  the 
results  obtained  are  of  no  value  to  the  practical  physiologist.  In  the 
living  body  the  conditions  for  the  interchange  of  water  and  the  con- 
stituents of  solutions  through  membranes  are  evidently  exceedingly 
complex,  for  in  spite  of  the  magnificent  labors  of  Dudrodet,  Graham, 
Pfeffer,  Vant  Hoff,  and  others,  the  enigma  of  the  physical  chemistry 
of  protoplasm  still  puts  a  limit  to  the  physiologist's  conception  of 
the  modes  of  motion  of  fluids  through  the  membranes  of  the  body." 

But  when  Professor  Starhng  comes  to  Bright's  disease  dropsy  he 
quits  the  field  precipitately,  thus,  "One  of  the  most  important  forms 
of  dropsy,  namely,  that  which  accompanies  renal  disease,  was  placed 
by  Cohnheim  in  the  category  of  inflammatory  dropsy,  and  that  seems 
a  necessary  conclusion,  in  view  of  the  fact  that  we  are  unable  to  trace 
any  adequate  mechanical  cause,  such  as  raised  mechanical  pressure,  to 
the  increased  transudation.  We  know  very  little  more  about  this 
form  of  dropsy  than  was  known  in  Cohnheim's  time."  We  would 
simply  add,  that  however  Httle  we  know  about  the  matter  now,  we  do 
know  that  typical  renal  dropsy  has  not  a  single  inflammatory  element 
in  it. 

Much  the  most  decisive  experiment  in  illustrating  this  subject  is, 
in  our  opinion,  that  of  Leathes  and  Starling,  who  first  induced  pleurisy 
on  one  side  by  the  injection  of  extract  of  jequirity  into  the  sac,  having 
previously  ascertained  by  autopsy  how  long  it  took  an  animal  to  recover 
from  this  pleurisy  so  that  the  membrane  was  restored  to  a  wholly  healthy 
state.  They  then  induced  artificial  plethora  by  injecting  large  quanti- 
ties of  normal  saline  into  the  blood  of  a  dog,  which  had  had  time  quite 
to  recover  from  its  artificially  induced  pleurisy.  But  the  dog  speedily 
perished  by  asphyxia  from  an  enormous  effusion  into  the  pleura  of  the 
side  which  had  been  experimented  on,  while  there  was  no  effusion 
whatever  on  the  other  side.  Now,  certainly,  that  recent  inflammation 
should  change  this  serous  membrane  into  a  tissue  no  better  than  a 
piece  of  muslin  to  hold  increased  blood  tension,  is  a  fact  of  great  sig- 
nificance. It  shows  that  weakened  nutrition  of  the  walls  of  the  blood- 
vessels is  probably  the  leading  factor  in  all  dropsies,  and  this  devitali- 
zation may  be  produced  in  various  ways,  either  by  impoverishment  of 
the  blood,  by  inflammation,  or  by  blood-poisoning,  as  in  renal  dropsy. 


SIGNIFICANCE   OF   VOMITING  6 1 

SIGNIFICANCE  OF  VOMITING 

The  vomiting  center  in  the  medulla  is  the  most  susceptible  of 
nervous  centers,  and  hence  the  exciting  causes  of  this  symptom 
outnumber  those  of  all  other  single  morbid  signs  which  we  have 
mentioned,  yet  scarcely  once  in  ten  cases  of  vomiting  will  the  stomach 
be  found  to  be  itself  at  fault.  Its  significance,  therefore,  is  very  vari- 
able, meaning  httle  in  one  case,  and  enough  in  another  to  make  it  a 
most  important  danger-signal.  Amid  such  a  diversity  of  causes,  rang- 
ing from  a  brain  tumor  to  a  renal  calculus,  or  from  the  onset  of  pneu- 
monia to  seasickness,  it  is  best  to  begin  with  those  signs  which  show 
that  the  stomach  is  vomiting  on  its  own  account  and  is  to  be  dealt  with 
accordingly. 

Any  inflammatory  process  in  this  viscus  will  excite  vomiting,  but 
this,  then,  will  be  associated  with  other  symptoms  which  are  valuable 
for  definitely  indicating  that  such  a  condition  of  the  stomach  is  the 
cause  of  the  disturbance  and  not  something  else.  Those  signs  which 
are  never  absent  are  tumefaction  of  the  epigastrium,  with  muscular 
rigidity  and  more  or  less  tenderness  on  palpation.  In  severe  acute 
gastritis,  pain  is  also  pronounced  and  is  referred  to  the  stomach  itself, 
while  there  is  more  or  less  fever  with  persistent  nausea.  The  vomitus 
shows  first  the  stomach  contents,  then  mucus,  bile,  and,  after  severe 
retching,  streaks  of  blood.  Owing  to  the  dry  state  of  the  mucosa,  which 
becomes  coated  with  viscid  mucus,  there  is  much  thirst.  Liquids  may 
then  be  freely  allowed,  which  by  dissolving  the  mucus  diminish  the 
retching  enough  to  make  the  vomiting  easier.  In  some  cases  the 
stomach  is  so  irritable  that  a  teaspoonful  of  water  is  at  once  rejected. 
A  couple  of  leeches  appHed  to  the  epigastrium  may  then  prove  ser- 
viceable to  lessen  both  the  pain  and  the  vomiting. 

In  chronic  gastritis  vomiting  is  very  frequent,  but  more  intermittent. 
Such  is  the  morning  vomiting  of  old  alcoholics,  when  their  thirst  leads 
them  also  to  drink  quantities  of  water.  If  questioned,  they  ascribe 
their  nausea  to  catarrh  of  the  head  dropping  down  the  throat,  an  im- 
pression strengthened  by  the  amount  of  mucus  which  they  bring  up. 
Here,  again,  tumefaction  of  the  epigastrium  with  rigidity  and  tender- 
ness to  palpation  are  diagnostic. 

In  ulcer  of  the  stomach  vomiting  occurs,  as  a  rule,  soon  after  taking 
food  if  the  ulcer  be  near  the  cardia,  but  more  delayed  if  near  the  py- 
lorus, and  here  pain  and  local  rigidity  with  throbbing  often  occur. 
If  the  vomiting  does  not  come  on  until  more  than  an  hour  after  taking 
food,  the  pain  meantime  increasing,  there  is  reason  to  apprehend  the 
complication  of  spasm  of  the  pylorus.     The  vomitus  should  be  care- 


62  CLINICAL  MEDICINE 

fully  inspected  for  signs  of  blood,  which  may  be  detected  in  about 
one-third  the  cases  of  gastric  ulcer,  though  not  in  amount  to  be  termed 
hematemesis. 

Vomiting  may  be  of  particular  significance  in  diagnosis  of  gastric 
cancer.  If  a  patient  after  middle  hfe,  who  has  not  had  stomach  troubles 
before  and  has  been  temperate  in  eating  and  drinking,  begins  to  suffer 
from  dyspepsia  with  a  sense  of  a  load  in  his  stomach,  then  persistent 
nausea,  and  finally  vomiting,  malignant  disease  is  to  be  apprehended, 
though  no  other  local  signs  are  yet  appreciable.  Cancer  of  the  fundus 
may  develop  into  a  large  tumor  without  vomiting,  but  if  the  location 
be  either  at  the  cardia  or  pylorus,  nausea  and  vomiting  are  rarely 
absent.  It  may  recur  repeatedly  during  the  day,  but  if  stricture  of  the 
pylorus  develops,  causing  gastric  dilatation,  the  vomiting  may  be  de- 
ferred for  several  days,  and  then  be  great  in  amount,  with  much  decom- 
position of  the  contents.  This  happens  also  in  dilatation  of  the  stom- 
ach from  other  causes.  In  the  early  stages  of  cancer  the  ejecta  may 
not  differ  from  those  of  chronic  gastritis,  but  the  vomiting  of  blood 
becomes  almost  pathognomonic  of  cancer  when  it  has  the  appearance 
of  coffee-grounds  or  dark  chocolate,  and  is  kept  up  for  days  together. 

The  most  serious  significance  attached  to  vomiting  is  when  it 
accompanies  some  accidents  to  an  abdominal  viscus.  Many  Hves 
have  been  sacrificed  from  failure  to  recognize  in  time  the  import  of  the 
association  of  the  symptoms  with  abdominal  pain.  An  appendicitis 
begins  to  be  a  serious  matter  when  repeated  vomiting  comes  on,  like- 
wise an  intestinal  obstruction  of  any  kind  or  a  hernia,  or  volvulus,  or 
an  intussusception.  If  the  precise  lesion  be  concealed,  or  not  easily 
located,  nevertheless  abdominal  pain  with  vomiting  means  a  danger. 
It  will  be  a  rehef  to  find  by  their  proper  signs  that  a  hepatic  or  a  renal 
calculus  is  the  cause  of  both  these  symptoms,  for  then  morphin  may 
be  injected,  but  not  so  if  no  such  explanation  is  forthcoming.  The 
supervention  of  peritonitis  upon  an  abdominal  derangement  may  be 
apprehended  if  vomiting  sets  in,  because  peritonitis,  if  at  all  extensive, 
always  causes  vomiting,  the  ejecta  then  being  usually  of  a  grass-green 
color. 

Sir  Wm.  H.  Bennett  in  his  lectures  ('  'British  Med.  Jour.,"  March  24, 
1900;  "Lancet,"  July  8,  1905)  makes  some  valuable  recommendations 
about  the  treatment  of  vomiting  when  the  ejecta  are  putrid  or  sterco- 
raceous.  Such  vomiting  may  be  met  with  in  any  form  of  intestinal 
obstruction,  or  in  peritonitis  alone,  or  after  certain  abdominal  operations 
or  injuries.  His  recommendation  is  to  treat  such  vomiting  with  con- 
tinuous drafts  of  lukewarm  water,  for  though  they  are  immediately 


SIGNIFICANCE    OF    VOMITING  63 

vomited  again,  yet  in  time  the  stomach  becomes  quite  cleansed  of  its 
injurious  contents,  and  this  of  itself  is  a  great  recommendation. 

Vomiting  is  of  serious  import  when  it  occurs  in  tubercular  meningi- 
tis of  the  base  of  the  brain.  Its  characters  then  are  that  it  is  ejectile, 
but  the  abdomen,  instead  of  being  distended,  may  actually  be  retracted, 
with  none  of  the  rigidity  characteristic  of  gastritis.  Vomiting  is  also 
significant  when  it  comes  on  in  acute  fevers,  notably  at  the  onset  of 
pneumonia  and  of  scarlet  fever. 

Of  the  remaining  infections,  such  as  measles  and  typhoid,  vomiting 
is  not  an  initial  symptom. 


CHAPTER    III 

REMEDIES 

NON-HEDICINAL 

In  a  work  on  clinical  medicine  some  allusions  should  be  made  to 
the  action  of  remedies,  for  it  is  not  too  much  to  say  that  a  practitioner 
will  succeed  or  fail  according  to  his  use  of  remedies.  They  may  be 
divided  into  non-medicinal  and  medicinal.  Of  the  first  class  we  would 
mention  electricity,  cold,  heat,  and  change. 

Electricity. — Of  the  non-medicinal  remedies  some  of  the  recent  ap- 
pHcations  of  electricity  may  be  mentioned,  or  the  high-frequency 
currents  according  to  the  d'Arsonval  method.  The  application  of 
such  a  remedy,  however,  necessitates  the  use  of  an  electric  mechan- 
ism which  produces  a  high-frequency  current,  either  from  a  static 
machine  or  from  an  induction  coil.  Its  most  marked  effect  is  to 
reduce  a  pulse  of  high  tension,  the  existence  of  which  should  have  been 
proved  by  a  sphygmomanometer.  The  register  for  health  of  blood- 
pressure  varies  with  age — for  a  young  person  it  may  not  be  above 
140  to  160  mm.,  the  latter  figure  being  normal  for  a  person  forty-five 
years  of  age.  After  that  it  rises  with  each  year,  reaching  200  in 
many  cases  at  seventy  years,  but  the  condition  is  often  morbid,  and 
caused  by  arteriosclerosis  and  by  chronic  kidney  disease,  when  it 
rises  to  200  to  220  or  even  250  mm.  Anyone  with  such  a  blood- 
pressure  as  this  is  in  danger  of  the  formation  of  aneurysms  or  of  apo- 
plexy. The  d'Arsonval  current,  however,  is  a  very  efficacious  means 
for  reducing  the  blood-pressure  even  below  what  would  be  the  normal 
for  the  patient's  age.  It  does  so  for  a  few  hours  only,  but  if  the  appli- 
cations be  kept  up  twice  a  day  or  every  day  it  often  causes  a  more  or 
less  permanent  reduction  in  arterial  tension.  One  other  property  of 
electricity  may  be  here  mentioned,  which  is  the  local  dilatation  of  any 
superficial  arteries  by  a  battery  of  the  ordinary  interrupted  faradic 
current.  By  this  means  a  local  increase  in  the  rapidity  of  the  arterial 
blood  may  be  caused  between  the  poles  of  the  battery,  however  near 
they  may  be  to  each  other.  This  enables  us  to  restore  the  muscular 
contractihty  when  it  is  lost  in  very  small  muscles,  such  as  the  interossei 
of  the  fingers.     Equally  a  rapid  arterial  current  causes  absorption  of 

64 


NON-MEDICINAL  65 

the  exudation,  and  hence  I  have  used  this  for  removal  of  opacities  of 
the  cornea  caused  by  antecedent  inflammation.  What,  however,  is 
useful  for  small  areas,  can  be  equally  beneficial  in  all  inflammatory 
effusions,  so  that,  with  one  pole  of  the  battery  appUed  at  the  nape 
of  the  neck  and  the  other  passed  over  the  surface  of  the  corresponding 
side  of  the  chest,  quite  an  extensive  effusion  into  the  pleura  and  other 
inflammatory  exudates  may  be  absorbed,  on  the  same  principle  that  a 
blister  causes  disappearance  of  an  effusion  by  increasing  the  flow  of 
the  arterial  current  underneath.  On  the  same  principle,  joints  that 
have  been  fettered  by  chronic  rheumatic  inflammation  may  be  set 
free  by  the  frequent  repetition,  two  or  three  times  a  day,  of  the 
faradic  current,  the  poles  being  laid  at  opposite  points  on  the  joint. 

The  Action  of  Cold. — This  class  of  remedies  owe  their  properties 
to  actions  upon  the  vasomotor  nerves,  of  which  cold  is  a  good  illus- 
tration. Cold,  as  an  irritant  is  per  se  depressing,  but  it  has  the  char- 
acteristic effect  of  producing  a  reaction  when  its  impression  ceases. 
So  long  as  the  impression  of  cold  is  felt,  it  produces  arterial  contrac- 
tion and  anemia  of  the  part.  This  property  may  be  of  use  in  localized 
inflammations,  as  in  joints,  by  the  application  of  ice-bags  to  them. 
Care  should  be  takeh,  however,  not  to  continue  the  appHcation  too 
long.  Ice-bags  should  never  be  applied  directly  to  the  skin  without 
the  interposition  of  a  cloth  of  some  kind,  for  the  anemia  induced  may 
cause  gangrene.  It  is  a  safe  rule  to  be  guided  by  the  sensation  of  the 
patient.  So  long  as  the  appKcation  of  cold  reUeves  pain  and  reduces 
swelling  it  may  be  continued  until  the  application  becomes  disagree- 
able, whereupon  it  should  be  discontinued  at  once.  Thus,  after  a 
fracture  or  other  cause  of  local  inflammation,  the  appHcation  of  ice- 
bags  may  be  kept  up  beneficially  for  three  weeks,  but  the  very  next 
day,  if  the  cold  is  no  longer  agreeable  to  the  patient,  it  should  be  dis- 
continued. In  cases  of  uncertainty  the  ice-bags  should  be  removed  to 
test  whether  the  pain  of  the  inflammation  returns  or  not.  If  the 
patient  feels  better  without  the  ice-bag  than  with  it,  cold  is  no  longer 
appKcable. 

On  account  of  the  constriction  in  the  arteries  cold  can  be  used  as 
a  hemostatic.  So  soon  as  the  direct  impression  of  cold  ceases,  it  is 
followed  by  a  reaction  which  constitutes  one  of  the  chief  remedial  uses 
of  cold.  This  reaction  produces  the  so-called  tonic  effect  of  cold  baths 
and  of  locally  cold  douches.  The  word  "tonic,"  however,  is  a  loose  and 
vague  term  derived  from  music,  and  suggests  a  comparison  with  the 
strings  of  a  vioHn  being  tightened  up,  but  under  this  term  such  entirely 
different  agents  as  iron,  cod-liver  oil,  arsenic,  quinin,  a  cold  bath^ 
5 


66  CLINICAL  MEDICINE 

and  a  sea  voyage  are  often  included.  Cold  as  a  tonic  acts  solely  by 
the  reaction  from  it.  If  the  primary  depression  of  cold  is  too  great 
for  adequate  reaction,  cold  is  the  very  opposite  of  a  tonic.  The 
degree  of  its  primary  irritation,  therefore,  must  always  be  carefully 
adjusted  to  the  patient's  powers  of  reaction.  The  cold  which  would 
invigorate  a  strong  man  by  a  shower-bath,  would  wholly  depress  a 
convalescent  from  a  fever;  who,  on  the  other  hand,  might  be  bene- 
fited by  a  shorter  and  milder  appUcation  of  this  agent,  such  as  by 
cold  sponging. 

Heat. — The  application  of  heat  to  a  part  differs,  whether  it  be 
dry  heat  or  moist  heat.  Dry  heat  is  a  pure  stimulant  and  moist  heat 
is  a  pure  sedative.  Dry  heat,  therefore,  may  be  apphed  for  the  pur- 
pose of  restoring  a  patient  from  heart  failure  or  syncope  by  the  use 
of  bottles  of  hot  water  or  similar  measures.  Care,  however,  should  be 
taken  in  cases  of  insensibihty  not  to  bhster  the  parts,  which  may  occur 
when  the  patient  has  recovered.  I  once  had  serious  trouble  with  the 
blistering  of  the  feet  from  hot  applications  while  the  patient  was  in- 
sensible. 

Dry  heat  applied  to  the  feet  is  our  most  efficient  emmenagogue 
through  the  vasomotor  associations  between  the  feet  and  the  circula- 
tion of  the  pelvic  viscera.  Cases  of  amenorrhea  are  usually  character- 
ized by  prolonged  coldness  of  the  feet,  especially  on  retiring  to  bed,  but 
by  persistent  heating  of  the  feet  by  various  means,  such  as  warm  soap- 
stones  or  other  foot  warmers,  I  have  succeeded  eventually  in  restoring 
the  menstrual  functions  which  had  been  suppressed  for  several  years. 
Moist  heat,  on  the  other  hand,  is  always  sedative,  as  is  illustrated  by 
the  applications  of  poultices  to  relieve  pain.  It  produces  relaxation 
of  muscular  spasm,  whether  it  be  spasm  of  the  arteries  or  of  the  sys- 
temic muscles.  In  the  days  preceding  the  knowledge  of  anesthetics, 
patients  with  dislocation  of  the  hip-joint  were  immersed  in  sitz-baths 
of  hot  water  until  they  felt  faint,  whereupon  the  relaxed  muscles  allowed 
of  the  restoration  of  the  dislocation.  There  is  no  agent  equal  to  moist 
heat  for  counteracting  muscular  spasm.  On  one  occasion  I  found  a 
man  at  the  Roosevelt  Hospital  who,  as  a  sequel  to  spinal  meningitis, 
had  every  muscle  of  his  arms  and  legs  thrown  into  rigid  contraction. 
His  heels  were  buried  in  his  buttocks,  and  the  knees  forced  together 
until  ulcers  formed  on  the  internal  condyles.  The  nails  also  had  grown 
into  the  palms  of  his  hands  from  inability  to  overcome  the  contraction 
of  the  flexors.  He  begged  not  to  be  touched  because  of  the  agonizing 
pain  produced  by  any  attempt  at  stretching  the  contracted  muscles. 
I  told  my  house  staff  that  we  would  enable  him  to  walk  out  of  the 


NON-MEDICINAL  67 

hospital  without  giving  him  any  medicine;  and  so  it  proved,  for  by 
douches  of  warm  water  continued  a  half-hour  at  a  time,  three  times  a 
day,  his  contractions  were  relieved,  and  two  months  afterward,  when 
I  met  him,  he  told  me  that  he  fell  overboard  from  a  boat  and  had  to 
swim  for  hLs  life.  Similar  success  may  be  expected  in  any  case  of 
joints  crippled  by  rheumatism,  however  prolonged  the  disabihty  has 
been,  by  the  use  of  douches  of  hot  water.  Unfortunately,  this  is  the 
case  only  with  rheumatic  stiffening,  for  if  caused  by  gout,  it  is  not  nearly 
so  successful. 

Change. — This  is  not  the  place  to  speak  of  the  great  part  which  is 
played  in  Hfe  by  habit.  Habit,  indeed,  is  the  main  organizer  of  the 
whole  nervous  system,  but,  apart  from  this,  every  practising  physician 
has  had  occasion  to  note  the  beneficial  effects  of  breaking  up  morbid 
habits  by  simple  change.  This  is  sometimes  wrongly  ascribed  to 
change  of  air.  But  as  many  a  resident  in  the  city  is  benefited  by 
going  to  the  country,  the  immediate  effect  of  which  is  to  improve  sleep 
and  appetite,  we  often  hear  the  change  ascribed  entirely  to  the  country 
air;  but,  on  the  other  hand,  the  farmer's  wife  is  as  much  benefited  by 
the  change  in  her  monotonous  Hfe  in  the  country  air  by  a  visit  to  her 
cousin  in  the  city.  The  real  cause  of  the  amehoration  Hes  in  the 
breaking  up  of  recurrent,  morbid  habits  by  alteration  of  surroundings; 
in  other  words,  by  simple  change.  A  prolonged  continuance  of  the 
same  impressions  without  change  is  always  injurious,  particularly  in 
the  case  of  nervous  diseases.  I  once  had  this  strikingly  illustrated  in 
the  instance  of  a  gentleman  who  suffered  from  the  grave  malady 
paralysis  agitans,  which  progressed  in  his  unvarying  Hfe  for  several 
years  at  his  country  place  until  he  could  no  longer  walk  across  the 
room  or  feed  himself,  and  finally  became  affected  in  his  speech.  I 
recommended  that  he  should  be  removed  to  his  city  residence;  and 
this  man,  after  taking  a  ride  of  some  twenty  miles  in  his  carriage,  got 
out  unaided,  walked  up  the  steps  of  the  house,  and  rang  the  door  bell. 
Two  days  afterward  he  walked  a  mile  to  my  ofifice  in  the  city,  and  ever 
after,  taking  the  hint  from  this  experience,  he  kept  up  changing  his 
surroundings,  staying  at  different  places  for  not  more  than  two  weeks 
at  a  time.  We  may  say  here  that  the  benefit  of  this  remedy,  change, 
is  usually  Hmited  to  two  weeks.  This  remedy  is  also  of  the  greatest 
use  by  altering  chronic  morbid  tendencies  which  so  often  culminate  in 
insanity.  Much  the  greater  number  of  cases  of  insanity,  if  investigated, 
will  prove  to  have  been  preceded  by  injurious  mental  habits  of  long  du- 
ration, and  nothing  so  commonly  arrests  this  dreadful  malady  at  its  be- 
ginning as  removing  the  patient  to  new  surroundings,  where  not  only 


68  CLINICAL  MEDICINE 

new  sights  but  new  faces  involuntarily  attract  his  attention,  and  thus 
displace  the  recurring  unhealthy  mental  habits. 

But  it  is  not  only  in  nervous  diseases  that  change  of  surroundings 
is  beneficial.  Serious  chronic  constitutional  disorders,  such  as  tuber- 
culosis and  Bright's  disease,  may  be  temporarily  and  yet  markedly 
benefited  by  change  of  scene  and  surroundings,  so  that  we  must  admit 
that  injurious  habits  of  nutrition  not  infrequently  complicate  con- 
stitutional disorders,  which  may  be  quite  advantageous  to  break  up 

by  mere  change. 

MEDICINAL 

A  medicine  is  a  remedy  which  acts  by  entering  the  circulation  in  a 
state  of  solution.  By  the  circulation  we  do  not  mean  only  the  blood- 
stream, for  the  interstitial  fluids  outside  of  the  blood-vessels  are  also 
in  constant  and  rapid  movement,  as  is  shown  by  the  prompt  action 
of  soluble  medicines  given  hypodermically.  My  own  classification  of 
medicines  is  into  the  functional  and  constitutional  remedies.  The 
difference  between  function  and  structure  may  be  illustrated  by  an 
oil-lamp,  whose  function  is  to  give  Hght.  Now,  function  is  always 
deranged  by  derangement  of  structure,  but  the  reverse  is  not  true;  com- 
plete derangement  of  function  may  occur  without  any  derangement  of 
structure.  The  light-giving  function  of  a  lamp  may  be  destroyed  by 
injuring  the  lamp's  structure;  but  it  may  not  at  all  give  Hght,  while  its 
structure  is  perfectly  intact,  if  its  wick  is  immersed  in  water  instead  of 
in  oil. 

The  functional  medicines  have  no  effect  upon  the  constitution,  but 
only  act  upon  its  functions  or  modes  of  working.  Their  great  charac- 
teristic is  that  their  whole  action  is  secured  by  one  dose. 

However  often  that  dose  be  repeated,  the  last  dose  does  not  pro- 
duce any  other  effects  than  the  first  dose.  This  is  illustrated  by  the 
inhalation  of  the  smoke  of  stramonium  leaves  for  the  rehef  of  an  asth- 
matic paroxysm.  Though  this  inhalation  may  be  practised  for  years, 
the  only  effect  which  it  produces  is  to  reHeve,  each  time,  the  symptom 
spasm  of  the  bronchial  muscles,  while  the  disease  asthma  continues 
as  before.  A  functional  remedy  does  not  produce  any  constitutional 
effects,  however  large  or  dangerous  its  dose.  A  man  may  come  very 
near  death  from  an  overdose  of  opium,  but  if  he  recovers,  in  twenty- 
four  hours  he  shows  no  more  effects  from  this  poison. 

A  constitutional  medicine,  on  the  other  hand,  does  not  produce  any 
apparent  effects  by  one  dose,  but  only  after  the  prolonged  and  sys- 
tematic administration  of  many  doses,  such  as  in  the  treatment  of 
anemia  by  iron,  or  of  syphiHs  by  mercury.     Constitutional  medicines, 


MEDICINAL  69 

therefore,  do  not  relieve  symptoms,  for  the  symptoms  only  disappear 
with  the  cure  of  the  disease.  In  other  words,  functional  medicines 
relieve  symptoms  only,  while  constitutional  medicines  relieve  not  only 
symptoms,  but  also  the  diseases  themselves. 

Functional  medicines  are  divisible  into  three  classes:  first,  the  ner- 
vines, or  those  which  act  upon  some  nervous  function;  second,  the 
eliminatives,  or  those  which  increase  gland  secretion — these  are 
divisible  into  emetics,  cathartics,  diaphoretics,  and  diuretics;  and  the 
third  class  are  the  astringents,  which  cause  muscular  and  fibrous  tissues 
to  contract.  Now,  as  to  nervines^  there  is  no  general  nervous  anything; 
there  is  no  general  nervous  stimulant  or  general  nervous  sedative, 
except  death.  The  most  important  members  of  this  class  are  those 
which  are  both  stimulants  and  sedatives  at  the  same  time,  but  they 
are  so  because,  being  always  partial  in  their  effects,  they  may  stimulate 
certain  nervous  functions,  while  they  depress  others.  Thus,  opium  is 
a  powerful  stimulant  to  the  brain  or  to  mental  functions,  and  is  taken 
for  that  purpose  by  opium  habitues.  It  is  also  a  stimulant  to  the  heart, 
causing  it  to  beat  very  regularly  and  the  arteries  to  dilate,  so  as  to 
give  a  full  pulse.  While  it  is  thus  acting,  it  simultaneously  depresses 
or  checks  the  secretions  and  the  movements  of  the  gastro-intestinal 
tract,  and  reheves  pain  in  inflammations. 

Other  divisions  of  the  nervines  are  those  which  are  pure  stimu- 
lants, of  which  ammonia  is  an  example,  and  those  which  are  pure  seda- 
tives, such  as  hydrocyanic  acid.  The  ehminants  or  stimulants  of 
gland  secretions  are  fully  described  by  their  names.  They  also  act  only 
in  one  dose,  for  if  one  takes  a  cathartic  he  does  not  expect  to  wait  until 
the  following  week  before  it  operates;  so  the  astringents  are  sufficiently 
explained  by  their  names. 

Certain  facts  about  the  functional  medicines  should  be  noted, 
namely,  that  their  actions  are  always  physiologic,  and  show  the  same 
effects  in  health  as  in  disease.  Opium  or  strychnin  would  have  the 
same  characteristic  effect  upon  the  healthy  as  upon  the  sick.  It 
follows,  therefore,  that  we  do  not  get  the  effects  of  any  functional 
medicine  as  a  remedy  until  it  produces  its  physiologic  symptoms. 
Thus,  in  gangrene,  in  which  opium  is  of  great  service  as  a  stimulant, 
it  may  have  to  be  given  in  doses  ten  times  as  large  as  usual  before  the 
characteristic,  physiologic  symptoms  of  opium,  such  as  contracted 
pupils  and  slowing  of  the  breathing,  develop. 

The  same  may  be  said  of  veratrum  viride  when  given  to  reduce  the 
tension  of  the  pulse  in  puerperal  convulsions.  Here,  instead  of  5 
drops,  1 20  drops  may  be  necessary  to  show  any  effects  upon  the  pulse. 


70  CLINICAL   MEDICINE 

The  constitutional  or  disease  medicines  may  be  divided  into  two 
classes:  those  which  are  natural  to  the  system  and  presumably  act 
by  making  up  some  deficiency,  such  as  iron  in  non-febrile  anemia,  and 
hence  may  properly  be  termed  restoratives ;  or  those  which  are  unnat- 
ural to  the  system,  such  as  mercury,  iodin,  bromin,  or  arsenic,  which 
class  is  usually  termed  alteratives.  Being  unnatural  to  the  system, 
these  agents  are  poisonous,  but  it  must  always  be  borne  in  mind  that 
their  poisonous  action  is  not  the  same  as  their  remedial  action.  When- 
ever, therefore,  they  show  symptoms  of  their  poisonous  actions  they 
cease  to  be  remedies,  and  their  dose  should  be  lessened  or  abandoned. 
Thus,  when  mercury  produces  salivation,  or  iodin  produces  the  symp- 
toms of  iodism,  or  the  bromids  produce  symptoms  of  bromism,  they 
are  no  longer  acting  as  remedies.  In  their  administration,  therefore, 
care  should  be  taken  to  avoid  all  symptoms  of  poisoning  by  them. 
The  vaHdity  of  this  principle  is  shown  by  the  fact  that  mercury  can 
act  as  a  cathartic  or  functional  ehminative  medicine,  and  is  often  given 
for  that  purpose,  but  if  so,  it  ceases  to  act  for  the  time  as  a  constitu- 
tional medicine. 

In  some  cases,  however,  the  action  of  constitutional  medicines  is 
promoted  by  combining  with  them  some  of  the  functional  medicines 
which  reheve  the  symptoms  of  the  disease.  Thus,  arsenic  and  potas- 
sium iodid  belong  to  the  constitutional  medicines,  but  in  the  treatment 
of  asthma,  as  an  example,  it  is  well  to  combine  with  both  these  medi- 
cines such  functional  medicines  as  belladonna  and  the  compound 
spirits  of  sulphuric  ether  in  the  same  prescription  with  the  arsenic  and 
the  iodid. 

It  is  a  good  rule  to  postpone  as  long  as  possible  the  poisonous  effects 
of  alteratives  by  simultaneously  administering  restoratives  for  that 
purpose. 

VACCINES 

By  John  Edgar  Welch,  M.  D.,  New  York  City 

The  science  of  bacteriology,  by  establishing  the  etiologic  relation 
of  bacteria  to  pathologic  processes,  both  of  a  local  and  general  char- 
acter, opened  a  new  field  for  observation  and  study. 

It  was  soon  observed  that  organisms  act  in  two  ways  in  producing 
the  cHnical  reactions  we  know  as  disease.  In  one  instance,  best  illus- 
trated by  the  diphtheria  bacillus,  the  organism  lodges  on  a  mucous 
membrane  surface,  usually  over  the  tonsil  and  adjacent  parts,  where 
it  multiplies  without  entering  into  the  tissues  or  circulation.  During 
its  development,  however,  it  Hberates  a  toxin,  which  is  to  be  consid- 


VACCINES  71 

ered  as  a  metabolic  product  of  its  growth.  This  toxin  is  absorbed 
by  the  tissues  and  circulates  in  the  blood,  producing  the  symptoms  of 
diphtheria. 

Typhoid  fever  represents  a  clinical  reaction  which  is  produced  in 
another  manner.  In  this  disease  the  Bacillus  typhosus  gains  entrance 
to  the  circulating  blood  and  organs  of  the  body,  especially  the  spleen. 
Numerous  bacilH  are  constantly  being  killed  and  disintegrated  by  the 
defensive  agents  of  the  body.  In  the  process  of  disintegration  a  toxin 
is  discharged  into  the  body  fluids  which  gives  the  disease-picture  we 
call  typhoid  fever.  The  poison  of  the  typhoid  bacillus  does  not 
escape  from  the  live,  intact  micro-organism  in  which  it  is  firmly  held, 
but  can  be  Uberated  only  upon  the  death  and  disintegration  of  the 
micro-organism. 

The  toxin  of  the  diseases  illustrated  by  diphtheria  is  called  exo- 
toxin, and  is  Hberated  freely  by  the  hving  micro-organism.  The 
toxin  of  the  diseases  illustrated  by  typhoid  is  called  endotoxin,  and  is 
hberated  only  upon  the  disintegration  of  the  micro-organism. 

It  is  against  the  class  of  micro-organisms  furnishing  endotoxins 
that  vaccine  is  employed  as  a  therapeutic  and  prophylactic  measure. 

Immunity,  whether  active  or  passive,  is  a  state  which  is  imperfectly 
understood.  However,  the  serum  of  those  enjoying  this  condition 
shows,  usually,  three  substances  which  are  known  to  take  active  part 
in  combating  bacteria.  These  are:  opsonins,  amboceptor  (antibody), 
and  agglutinins,  all  of  which  can  be  produced  in  the  serum  of  non- 
immune animals  by  the  intraperitoneal  injection  of  bacteria. 

The  opsonin  is  a  substance  which  sensitizes  the  bacterium  in  such 
a  way  that  it  is  prepared  for  ingestion  by  the  polymorphonuclear  leuko- 
cytes. But  for  this  opsonic  action  the  leukocytes  would  be  incapable 
of  acting  as  phagocytes. 

The  amboceptor  is  a  reaction  body  which  sensitizes  the  bacterium 
and  prepares  it  for  digestion  by  the  ferment  called  "complement," 
which  is  a  constituent  of  all  normal  sera. 

Agglutinin  is  a  substance  appearing  in  the  serum  of  an  animal 
after  inoculation  with  bacteria  which  causes  the  bodies  of  the  bacteria 
to  adhere  to  each  other.  The  exact  interpretation  of  this  phenomenon 
is  impossible.  It  is  observed  frequently  to  precede  disintegration  of 
bacilli  and  is  supposed  to  have  some  intimate  relation  to  that  process. 
Just  how  active  agglutinin  is  in  contributing  to  immunity  is  not  cer- 
tain, but  it  is  definitely  known  that  the  opsonin  and  amboceptor  are 
very  important  factors,  especially  the  opsonin.  It  is  this  body  that 
is  produced  in  abundance  after  the  injection  of  vaccine. 


72  CLINICAL  MEDICINE 

The  term  "vaccine"  is  applied  to  a  suspension  of  killed  bacteria 
in  normal  salt  solution,  and  is  not  to  be  confounded  with  serum. 
Vaccines  are  administered  by  means  of  a  needle  and  should  be  in- 
jected intramuscularly.  They  should  be  made  from  the  same  variety 
of  organism  which  is  infecting  the  patient,  and,  if  possible,  made  from 
cultures  taken  directly  from  the  patient,  in  which  case  the  vaccine 
would  be  designated  "autogenous"  to  distinguish  it  from  "stock  vac- 
cine," which  is  made  from  the  same  organism,  but  another  strain,  i.  e., 
from  some  other  source  than  the  infected  individual,  and  kept  in  stock. 

Vaccines  are  used  both  as  a  prophylactic  and  therapeutic  measure, 
but  in  the  field  of  prevention  seem  to  have  proved  of  most  value. 
The  United  States  Army,  by  means  of  prophylactic  vaccination  of 
troops  against  typhoid  fever,  has  practically  eHminated  this  disease 
from  among  the  enlisted  men. 

As  a  therapeutic  measure  vaccines  are  used  both  in  local  infections 
and  in  bacteremia.  In  the  latter  condition  great  care  and  judgment 
should  be  exercised  in  their  employment.  Those  cases  of  bacteremia 
which  have  high  temperature,  rapid  pulse,  and  otherwise  show 
signs  of  a  severe  infection,  are  probably  reacting  to  their  bacterial 
infection  to  the  full  extent  of  their  ability.  An  injection  of  vaccine 
under  these  conditions  probably  adds  fuel  to  the  fire,  and  the  fresh 
acquisition  of  poison  by  the  system  is  Hable  to  be  detrimental  rather 
than  beneficial.  On  the  other  hand,  those  cases  of  bacteremia  which 
tend  to  run  a  more  protracted  course,  with  little  fever,  are  apt  to  im- 
prove by  the  vaccine  treatment  through  the  fact  that  their  immunity 
apparatus  is  stimulated  to  greater  activity. 

The  local  superficial  infections,  such  as  furuncles,  abscesses,  etc., 
furnish  more  favorable  conditions  for  vaccine  treatment.  The  in- 
flammatory process  surrounding  any  localized  infection  prevents  a 
free  passing  of  the  toxins  into  the  general  circulation.  In  consequence, 
the  organs  contributing  to  immunity  lack  sufficient  stimulus  for  the 
formation  of  opsonin  and  amboceptor  in  sufficient  quantity  to  properly 
overcome  the  local  focus  of  organisms.  By  the  injection  of  vaccine 
the  production  of  immunity  bodies  is  stimulated  in  sufficient  quantity 
to  overcome  the  local  focus  of  bacteria. 

In  addition  to  its  good  results,  as  above  mentioned,  vaccine  has 
proved  of  considerable  value  when  used  against  infections  of  mucous 
membrane  surfaces,  such  as  colon  bacillus,  pyelitis,  and  cystitis. 


PART  II 
THE   INFECTIONS 


CHAPTER    I 


GENERAL  INTRODUCTION  AND  CLASSIFICATION 

The  subject  of  the  infections  leads  into  the  widest  fields  of  medical 
science.  But  those  fields  all  He  within  lo  inches  from  the  naked  eye, 
and  therefore  could  have  been  explored  only  by  the  invention  of  the 
modern  microscope.  In  that  field  a  vast  kingdom  of  life  has  been  thus 
discovered  to  whose  forms  the  term  "micro-organism"  has  been  given. 
Among  such  micro-organisms  are  those  infectious  agents  whose  en- 
trance into  our  bodies  and  multiplication  there  occasion  their  corre- 
sponding distress. 

That  these  infectious  agents  are  true  growths  is  proved  by  their 
reproduction  being  specific.  They  always  breed  true.  Measles  can- 
not cause  anything  but  measles,  and  not  scarlatina,  with  which  it  was 
at  first  confounded,  any  more  than  the  seed  of  a  turnip  can  produce  a 
carrot.  It  is  now  universally  admitted  that  each  infectious  disease 
is  caused  by  its  own  specific  germ  and  by  no  other. 

We  now  know,  however,  that  micro-organisms  constitute  the  largest 
as  well  as  the  most  ancient  division  of  the  kingdom  of  life,  for  whereas 
all  -visible  forms,  whether  of  plant  or  animal,  are  necessarily  local,  the 
micro-organisms  are  everywhere  where  life  is  possible. 

To  their  living  activities  are  due  the  vast  majority  of  deaths,  be- 
cause only  an  insignificant  fraction  die  by  storm,  flood,  earthquake, 
or  similar  physical  accidents.  Deaths  by  micro-organisms  are  not 
accidental,  but  natural,  for  even  derangements  of  vital  organs,  like 
those  of  the  heart  and  kidneys,  simply  prepare  the  way  for  those  so- 
called  terminal  infections  by  vast  numbers  of  micro-organisms,  which 
are  the  immediate  cause  of  dissolution. 

As  all  forms  of  Hfe  come  from  previous  forms  of  life,  so  is  death  a 
characteristic  of  life  only.  A  stone  never  dies;  nothing  dies  unless  it 
has  first  lived.     Hence  death  is  a  necessary  factor  in  Kfe,  and  there  can 

73 


74  CLINICAL   MEDICINE 

be  no  life  without  the  way  be  prepared  for  it  by  death.  Thus  no  tree 
which  falls  in  the  forest,  nor  the  body  of  a  beast  dying  in  the  field 
would  decompose  spontaneously  any  more  than  would  stones.  But  so 
soon  as  plant  or  animal  dies,  their  remains  are  at  once  attacked  by 
microbes  to  resolve  them  back  to  dust.  Therefore,  but  for  micro- 
.  organisms  the  earth  would  soon  be  choked  with  its  own  dead. 

It  is  natural  that  micro-organisms  should  be  regarded  with  dread 
as  causes  only  of  disease  and  death.  But  this  is  far  from  the  whole 
truth.  The  great  majority  of  these  infinitely  numerous  Hving  things 
are  harmless  to  us,  and  many  of  them  actually  beneficial.  It  is  only 
certain  of  them  which  cause  disease  by  multiplying  in  our  bodies. 

These  latter  are  divisible  into  two  classes:  first,  the  facultative 
parasites,  which  may  five  outside  the  body,  but  become  causes  of 
disease  when  they  gain  entrance  into  it.  Thus  the  tetanus  bacillus  is 
one  of  these,  as  its  natural  habitat  is  in  the  soil,  and  can  become  fatal 
only  by  gaining  entrance  through  some  wound  or  similar  lesion.  These 
micro-organisms  are  also  called  saprophytes. 

ObKgate  parasites  are  those  which  can  five  and  multiply  only  in 
the  Hving  bodies  which  they  invade,  such  as  the  agents  of  small-pox 
and  typhoid  fever. 

It  should  be  here  noted  that  it  is  by  no  means  enough  for  patho- 
genic micro-organisms  to  gain  entrance  into  the  animal  body.  If  that 
were  all,  the  human  race  would  long  ago  have  become  extinct.  After 
they  gain  entrance  they  must  find  the  soil  suitable  for  them  to  grow 
and  to  multiply.  Their  mere  entrance  into  the  body  may  cause  no 
trouble.  Thus,  in  every  epidemic  of  diphtheria  its  specific  bacillus 
abounds  in  the  throats  of  attendants  on  the  sick  without  occasioning 
any  disease,  and  so  for  a  multitude  of  other  infective  agents,  such  as 
those  of  Asiatic  cholera,  cerebrospinal  meningitis,  pneumonia,  and, 
above  all,  tuberculosis. 

Micro-organisms  are  further  divisible  into  the  bacteria  which  have 
vegetable  affinities  and  the  protozoa  which  are  of  animal  nature. 
The  term  "bacterium,"  however,  is  a  misnomer,  derived  from  a  Greek 
word  meaning  a  rod,  but  the  most  formidable  members  of  this  class 
are  round  and  are  called  "cocci."  When  these  occur  in  pairs  they  are 
called  "diplococci,"  but  when  they  occur  adhering  together  in  chains 
they  are  termed  "streptococci,"  and  if  they  adhere  in  bunches  they  are 
named  "staphylococci."  The  bacilH  occur  in  the  form  of  rods  of  vary- 
ing length.  Many  bacteria,  whether  they  be  cocci  or  bacilh,  are 
contained  within  a  capsule;  they  are  all  unicellular  and  multiply 
by  simple  division. 


CLASSIFICATION    OF   INFECTIONS  75 

The  protozoa  are  of  comparatively  recent  discovery,  but  they  are 
constantly  gaining  in  number  and  importance.  Bacteria,  owing  to 
their  vegetable  nature,  can  be  cultivated,  and  hence  are  more  readily 
identified,  while  the  protozoa,  not  being  often  capable  of  cultivation, 
are  not  so  easily  identified.  Micro-organisms  are  of  many  different 
sizes,  some  of  them,  indeed,  are  too  small  to  be  seen  by  any  micro- 
scope, and  are,  therefore,  called  "ultramicroscopic."  They  are  also 
termed  "filterable,"  because  they  can  pass  through  the  extremely 
minute  pores  of  a  Berkefeld  porcelain  filter. 

The  diseases  caused  by  micro-organisms  are  further  divisible  into 
the  acute  or  short-time  diseases,  which  in  many  cases  are  definitely 
self-Hmited  in  their  course,  so  that  we  can  reckon  their  duration  by 
days  or  weeks.  Thus,  the  pneumococcus  causes  a  pneumonia  which 
lasts  but  a  few  days,  which  often  ends  abruptly  by  what  is  termed 
a  "crisis." 

The  typhoid  bacillus,  on  the  other  hand,  causes  a  fever  which  lasts 
for  several  weeks,  and  ends  gradually  by  what  is  termed  "lysis."  In- 
fections, again,  which  are  chronic  in  their  course,  such  as  tuberculosis 
and  s3^phLlis,  are  not  self-limited  or  else  they  would  not  be  chronic. 

CLASSIFICATION  OF  INFECTIONS 

The  term  "infectious"  should  be  appKed  to  all  diseases  caused  by 
the  entrance  of  a  micro-organism,  but  the  infections  by  them  occur 
in  a  variety  of  ways.  In  some  the  infection  commonly  occurs  directly, 
that  is,  by  mere  proximity  of  the  healthy  to  the  sick,  such  as  small- 
pox, scarlet  fever,  and  measles.  To  this  class  only  should  the  term 
"contagious"  be  appKed,  though  this  term  imphes  that  the  disease  is 
propagated  by  actual  personal  contact,  which  may  not  be  the  case. 
Yet  it  is  sufficiently  applicable,  if  by  it  is  understood  that  the  disease 
is  communicated  by  mere  proximity.  Such  diseases,  therefore,  can 
be  prevented  by  quarantine. 

The  second  class  are  those  by  which  communication  is  indirect 
through  some  intermediate  agent.  The  discovery  of  these  intermediate 
ways  of  communication  is  often  of  the  highest  advantage  to  the  com- 
munity, the  knowledge  of  which  would  have  prevented  many  disgrace- 
ful panics,  when  locahties  are  invaded  by  them  in  epidemic  form. 
Thus,  Asiatic  cholera  is  not  contagious,  for  it  does  not  spread  directly 
from  person  to  person,  but  only  by  swallowing  some  carrier  of  its  germs 
Kke  infected  water  or  articles  of  food  or  drink,  such  as  milk,  which  has 
become  infected  by  its  germs.  The  same  is  true  of  typhoid  fever, 
which  may  be  suspended  in  the  drinking-water  of  a  town. 


76  CLINICAL  MEDICINE 

The  third  class  of  infections  should  be  called  the  inoculable,  which 
enters  the  system  through  some  wound  or  similar  lesion  of  the  skin 
or  mucous  membrane,  such  as  hydrophobia,  by  the  bite  of  rabid  ani- 
mals, or  through  direct  inoculation  by  an  insect,  such  as  in  yellow 
fever,  and  in  the  sleeping  sickness  of  Africa  and  in  all  malarial  fevers. 

All  that  is  claimed  for  this  classification  is  that  it  defines  the  usual 
mode  of  communication,  because  all  infectious  diseases  could  be  trans- 
mitted by  direct  injection  of  the  infected  blood,  which  method,  how- 
ever, is  rare. 

Besides  the  discovery  of  the  ways  by  which  the  infections  gain 
entrance  into  the  body,  it  is  important  to  know  how  they  leave  the 
body.  This  subject,  however,  will  be  best  treated  under  the  head 
of  each  disease,  which  only  can  conveniently  give  its  details.  It  is 
important,  however,  to  note  the  curious  fact  that  though  a  patient 
may  have  recovered  from  an  attack  and  thereby  have  become  immune 
against  its  return,  yet  he  may  for  long  periods  of  time  carry  the  specific 
germs  of  the  complaint,  while  so  immune,  and  thus  distribute  them  to 
others.  Thus,  typhoid  fever  rarely  attacks  the  same  person  twice, 
but  lately  we  have  discovered  that  many  typhoid  patients  after  their 
recovery  will  carr}^  the  typhoid  germs  for  months  or  even  years,  which 
they  can  communicate  to  others  by  means  of  urine  or  other  secretions. 

In  every  infection  the  outcome  will  depend  upon  the  balance  be- 
tween two  opposing  factors,  the  first  being  the  power  of  the  infecting  or- 
ganism itself,  and  the  second  the  vital  resistance  of  the  body  infected. 

To  the  infecting  power  the  term  "virulence"  is  given,  and  this  is. 
often  subject  to  marked  seasonal  variations.  Thus,  in  one  year  a 
given  epidemic  may  be  very  severe  in  its  incidence  and  in  the  compli- 
cations which  it  occasions,  while  in  another  year  it  is  much  milder  in 
both  these  respects. 

In  an  epidemic,  also,  the  cases  which  occur  at  the  beginning  or  during 
the  height  of  an  epidemic  are  usually  worse  than  those  happening 
during  its  decline. 

Thus,  during  a  winter  of  my  service  at  the  Roosevelt  Hospital,. 
30  cases  of  epidemic  cerebrospinal  meningitis  were  admitted,  of  whom 
of  the  first  16  all  died  except  2;  of  the  remaining  14,  all  Hved  except  2, 
while  the  treatment  of  both  classes  was  the  same.  The  explanation 
of  the  difference  was  that  the  first  class  was  taken  sick  during  the 
beginning  or  the  height  of  the  epidemic,  while  the  second  class  came 
during  its  decHne.  These  facts  should  be  borne  in  mind  when  esti- 
mating the  efficacy  of  any  special  fine  of  treatment,  for  we  ought 
first  to  know  at  what  period  or  season  the  epidemic  occurred. 


CLASSIFICATION    OF   INFECTIONS  77 

In  all  these  respects  the  infecting  organisms  behave  like  all  seeds, 
some  fall  by  the  wayside  where  they  cannot  grow,  and  therefore  come 
to  nothing.  In  another  individual  his  soil  produces  thirtyfold,  and 
he  is  made  correspondingly  sick;  in  another  it  produces  sixtyfold,  and 
is  much  more  sick;  in  another  the  yield  is  a  hundredfold,  and  quite 
enough  to  kill  him. 

We  find,  however,  that  we  can  increase  or  diminish  the  virulence 
of  these  agents  by  certain  changes  in  their  environment.  Thus, 
overcrowding  or  deficient  ventilation  or  poor  food  tend  to  increase 
virulence,  while  it  is  decreased  by  the  opposite  measures. 

It  is  important  to  know  that  very  generally  multiple  or  mixed 
infections  occur.  Hence,  it  should  be  the  aim  of  every  physician  to 
keep  the  infection  single,  for  if  he  does  this,  even  the  worst  of  them, 
like  tuberculosis,  may  become  comparatively  mild  infections.  The 
tubercle  bacillus  has  no  liking  for  fresh  air  and  is  killed  by  direct  sun- 
light in  seven  minutes,  but  in  the  cavity  of  the  peritoneum  there  is 
neither  air  nor  fight,  and  here  this  bacillus  may  produce  extensive 
changes,  so  that  the  surgeon  on  opening  the  abdomen  finds  the  peri- 
toneum abounding  with  tuberculous  masses,  which,  however,  then  get 
well  spontaneously.  The  explanation  is  that  the  infection  has  occurred 
all  alone,  and  that  it  has  become  much  weakened  by  its  brief  expo- 
sure to  fight  and  air,  so  that  the  vital  resistance  of  the  patient  is 
sufficient  to  put  an  end  to  it  in  its  enfeebled  condition.  In  like  manner 
tuberculosis  occurring  in  bones  is  not  commonly  disseminated  through 
the  system,  but  in  the  lung  the  tubercle  bacillus  finds  hosts  of  aUies 
in  the  shape  of  the  pyogenic  cocci,  which  cause  this  original  single  in- 
fection to  become  the  scourge  of  the  human  race.  A  good  illustration 
of  multiple  infections  happens  in  small-pox,  in  which  disease  we  may 
have  three  distinct  infections.  The  first  is  that  of  the  smaU-jx)x  agent 
itself,  which  has  not  yet  been  identified.  Its  onset  is  usually  sudden, 
accompanied  by  high  fever,  headache,  and  pains  in  the  back  and 
limbs;  the  stomach  also  becomes  very  irritable  and  the  tongue  coated. 
On  the  fifth  day  a  great  change  for  the  better  occurs;  the  fever 
drops,  the  pains  subside,  the  tongue  cleans,  and  the  stomach  becomes 
so  quiet  that  the  patient  may  be  hungry  and  want  to  eat.  But  by 
that  time  the  eruption  of  small-pox  begins  on  the  skin  in  the  form  of 
hard  pimples,  each  tipped,  however,  by  its  specific  fittle  vesicle.  To 
this  vesicle  ah  the  disastrous  subsequent  symptoms  are  due.  Thus 
the  surgeon,  before  he  attempts  to  cut  through  the  skin,  disinfects 
both  his  instruments  and  his  hands  in  order  to  prevent  the  entrance 
of  the  pyogenic  cocci,  which  always  swarm  upon  the  cutaneous  sur- 


78  CLINICAL   MEDICINE 

face.  Now,  what  the  surgeon  is  so  careful  to  prevent,  the  small-pox 
vesicle  allows  to  happen,  so  that  the  original  pimples  fill  up  with  pus 
and  soon  change  the  case  into  one  of  virtually  surgical  pyemia.  If 
the  patient  has  not  been  vaccinated  before,  the  pyemic  infection  be- 
comes far  worse  and  changes  the  case  into  confluent  small-pox,  but  if 
he  has  been  vaccinated  the  eruption  may  be  only  single  and  scattered, 
when  it  is  often  called  mild  varioloid.  In  view  of  these  facts,  to  call  a 
noisy  opponent  of  vaccination  an  ass  is  unfair  to  that  useful  quadruped,, 
for  he  often  shows  more  intelhgence  than  his  biped  rival  when  he  brays 
against  the  most  universally  harmless  inoculation  in  the  world. 

The  third  form,  or  malignant  small-pox,  is  fortunately  uncommon. 
In  this  the  patients  may  die  before  the  eruption  appears,  but  in  no 
other  form  is  the  disease  so  dangerous,  for  many  fatal  cases  have 
occurred  in  persons  who  unwittingly  attended  the  funerals  of  these 
patients.  All  that  is  found  is  a  remarkable  infection  of  the  blood 
by  vast  numbers  of  streptococci.  How  these  enter  we  do  not  know, 
because  small-pox  is  not  due  to  a  streptococcus,  else  it  would  have 
been  identified  long  ago. 

These  principles  find  also  special  applications  in  scarlatina  and  in 
diphtheria.  In  scarlatina  the  first  thing  that  happens  is  an  inflamma- 
tion of  the  throat  and  tonsils.  This  prepares  the  way  for  the  entrance 
into  the  blood  of  great  numbers  of  streptococci,  to  which  most  of  the 
fatahty  of  this  disease  is  due.  Diphtheria  often  attacks  the  throats 
of  patients  sick  with  scarlatina,  so  that  we  have  these  two  infections 
simultaneously.  But  diphtheria  is  at  first  a  purely  local  affection, 
its  membranes  secreting  the  toxin  which,  absorbed  into  the  blood, 
causes  all  the  serious  symptoms.  Meanwhile,  if  the  diphtheric  exuda- 
tion extends  deeply  enough  it  is  apt  to  become  gangrenous  and  ulcer- 
ated, whereupon  absorption  into  the  system  of  streptococci  occurs  on 
a  large  scale.  Owing  to  the  practical  importance  of  the  subject,  I 
would  here  relate  a  case  of  this  kind  which  I  saw  in  consultation  with 
Dr.  Geo.  Ferguson,  of  the  Bronx  Borough  of  New  York,  in  a  child 
five  years  old.  The  girl  first  had  an  attack  of  typical  scarlatina,  but 
on  the  fourth  day  diphtheria  set  in,  a  membrane  forming,  and  spread- 
ing so  rapidly  that  when  on  the  seventh  day  I  saw  the  patient  the 
exudation  had  hidden  both  the  tonsils,  the  uvula,  and  the  pharynx. 
The  glands  of  the  neck  on  both  sides  were  greatly  swollen,  the  patient 
could  not  swallow,  and  the  breath  had  a  gangrenous  odor.  I  told  the 
physician  that  it  was  useless  to  administer  any  medicine,  first,  because 
the  girl  could  not  swallow,  and,  second,  because  we  had  no  medicines 
against  the  exanthemata.     I,  therefore,  directed  that  we  should  wash 


CLASSIFICATION    OF   INFECTIONS  79 

out  the  throat  as  we  would  clean  a  dirty  sidewalk  with  a  hose.  A 
fountain-bag,  containing  2  gallons,  was  suspended  6  feet  over  the 
head  of  the  child,  and  a  steady  stream  of  hot  water  with  a  tea- 
poonful  of  chlorate  of  potash  and  5  drops  of  oil  of  peppermint  to  the 
gallon  was  poured  into  the  throat,  the  mouth  being  kept  wide  open 
so  that  none  of  this  douche  should  be  swallowed.  The  result  was  that 
this  douching  every  two  hours  brought  away  immense  quantities  of 
the  membrane,  and  after  keeping  up  this  douching  for  six  days  and 
nights  the  child  perfectly  recovered.  Now  what  was  accomplished 
in  this  case  was  that  both  the  exudate  of  diphtheria  and  the  infection 
of  the  streptococci  accompanying  the  scarlatina  were  washed  away 
as  soon  as  they  began  to  accumulate,  while  the  child's  vital  powers 
finally  carried  her  through,  when  they  could  work  without  ever}^  mo- 
ment a  fresh  infection  occurring. 

The  original  seat  of  an  infection  may  be  wholly  local.  We  have 
examples  of  this  in  diphtheria  and  in  Asiatic  cholera.  The  diphtheria 
bacillus  does  not  enter  the  blood,  but  usually  first  grows  and  spreads 
its  exudative  membrane  in  the  throat  and  adjoining  parts,  and  from 
these  surfaces  its  virulent  toxin  is  absorbed  into  the  circulation, 
hence  the  practical  importance  of  washing  the  infected  mucous  mem- 
brane clean.  But  this  also  applies  to  all  infections  which  begin  with 
angina  or  sore  throat  like  scarlatina.  The  cholera  vibrio  likewise  does 
not  enter  the  blood,  but  grows  exclusively  on  the  mucous  membrane 
of  the  small  intestine,  whence  its  toxin  is  then  absorbed.  Unfor- 
tunately, because  of  its  location,  we  cannot  wash  it  away. 

Local  infections  may  very  commonly  be  disseminated  by  metas- 
tasis, by  which  term  is  meant  transference  of  the  infecting  agent  from 
its  primary  seat  to  other  places  in  the  body  either  by  the  blood  or  by 
the  lymphatics.  A  striking  illustration  of  this  is  found  in  many  cases 
of-  pyemia. 

The  knowledge  ol  the  ways  by  which  infectious  micro-organisms 
leave  the  body  is  of  great  importance  for  prophylaxis.  Some  of  them 
leave  by  discharges  of  the  pathologic  products  which  they  have  caused, 
while  others  leave  the  body  by  secretions  from  the  blood  or  from  the 
mucous  membranes,  as,  for  example,  from  that  of  the  nasopharynx 
in  diphtheria  and  meningitis,  or  from  the  bronchial  tract  in  influ- 
enza, whooping-cough,  or  tuberculosis,  or  from  the  intestinal  mucous 
membranes  in  typhoid  fever,  cholera,  and  bacillary  dysentery.  The 
aim  of  the  physician,  therefore,  should  be  to  destroy  the  infecting 
agents  by  dealing  at  once  with  these  dangerous  discharges,  as  will  be 
noted  under  the  head  of  each  disease. 


CHAPTER    II 
AFFECTIONS  DIRECTLY  COMMUNICABLE  OR  CONTAGIOUS 
Acute  Infections  Directly  Communicable  or  Contagious 

plague  or  pestis 

This  is  much  the  most  anciently  known  and  destructive  of  dis- 
eases communicable  to  man.  Its  characters  are  so  peculiar  that  we 
can  have  little  doubt  as  to  its  identity  throughout  the  accounts  of  its 
occurrence  in  the  literature  of  all  countries  during  the  many  centuries 
of  its  prevalence.  In  one  pandemic,  occurring  in  1346,  it  is  estimated 
by  Hecker  to  have  destroyed  25,000,000  people,  although  Europe  was 
then  comparatively  very  thinly  populated,  and  its  fatality  has  not  at 
all  diminished,  for  the  reports  of  the  British  Government  of  its  prev- 
alence in  India  during  the  years  1905  and  1906  show  that  relatively 
to  the  population  the  death-rate  is  as  high  as  it  ever  was. 

It  is  also  the  most  anciently  known  to  us  of  all  epidemics,  and  is 
plainly  mentioned  in  the  fifth  and  sixth  chapters  of  I.  Samuel  in  the 
Bible.  Commentators  who  are  not  physicians  have  doubted  the 
identity  of  this  great  plague  among  the  Philistines  with  the  specific 
epidemic  known  throughout  the  centuries,  but  physicians  can  readily 
recognize  this  Biblical  reference  in  the  statement  that  it  was  accom- 
panied by  tumors,  and  that  it  had  something  to  do  with  rats,  so  that 
to  propitiate  the  angry  God  of  Israel  the  Philistines  sent  along  with 
the  ark  golden  representations  of  tumors  and  also  golden  rats.  The 
word  in  Hebrew  translated  "mice"  also  applies  to  rats.  But  it  was 
not  until  our  day,  thirty-five  centuries  after  the  Biblical  reference,  that 
Kitasato  identified  the  propagation  of  the  plague  through  the  bites  of 
fleas  which  had  been  living  on  plague-infected  rats. 

How  the  ancient  Philistines  came  to  suspect  that  rats  had  anything 
to  do  with  the  plague  is  very  natural  to  infer  from  the  fact  mentioned 
in  all  histories  of  this  disease  that  it  precedes  or  coincides  with  a  fatal 
epidemic  among  rats,  producing  veritable  buboes  in  them,  especially 
in  the  axillse  and  groins.  The  cause  of  this  epidemic,  so  fatal  that 
it  has  been  termed  "the  plague,"  is  the  Bacillus  pestis,  first  identified 
by  Kitasato,  who  was  deputed  by  the  Japanese  government  in  1894 

80 


PLAGUE    OR    PESTIS  8l 

to  investigate  the  disease  during  an  outbreak  in  Hong-Kong.  Kitasato 
found  numerous  bacilK  in  the  buboes,  heart-blood,  liver,  and  spleen. 
Similar  bacilli  were  also  found  in  a  living  case  of  plague  on  the  same 
day.  All  the  animals  inoculated  by  Kitasato  died  with  signs  not 
differing  from  those  of  human  bubonic  plague,  except  pigeons  and 
other  birds. 

The  plague  bacillus  as  found  in  the  buboes  and  blood  shows  a  con- 
siderable polymorphism,  of  which  two  forms  may  be  readily  recognized, 
namely,  short  oval  rods,  which  are  non-motile,  but  take  on  a  idgh 
degree  of  polar  staining,  the  micro-organism  appearing  stained  at  the 
ends,  but  not  so  in  the  middle. 

Pure  cultures  kept  in  the  dark  and  prevented  from  drying  can  Hve 
for  many  months,  and  are  but  httle  affected  by  their  surroundings 
becoming  putrefied.  In  fresh  water  the  bacillus  has  been  found  to 
exist  so  long  as  twenty  days.  Marsh  found  that  the  bacillus  could 
Hve  for  months  in  sterile  cow  dung.  The  only  active  general  agent 
against  these  plague  bacilh  is  light,  exposure  to  which,- according  to 
Kitasato,  kills  the  bacillus  in  less  than  three  hours.  Exposure  to  cold 
has  very  Httle  effect  on  the  plague  bacillus.  Thus,  Gladin  froze  and 
thawed  cultures  daily,  and  the  bacilli  were  still  aHve  after  forty  days  of 
such  treatment.  It  is  comforting  to  know  that  our  usual  chemical 
disinfectants  are  very  effective  against  the  plague  bacillus.  A  i  per 
cent,  solution  of  corrosive  sublimate  kills  the  bacillus  at  once,  a  i 
per  cent,  solution  of  carboHc  acid  kills  it  in  five  minutes,  and  a  i  per 
cent,  solution  of  calcium  chlorid  kills  it  in  ten  minutes. 

There  is  no  pathogenic  organism  which  seems  to  have  such  power 
over  the  great  majority  of  vertebrates.  So,  unhke  the  typhoid  fever 
bacillus,  which  can  only  affect  human  beings,  the  plague  bacillus  causes 
rats,  guinea-pigs,  and  monkeys  to  succumb  in  a  few  days  after  the 
inoculation  of  very  minute  quantities  of  plague  material,  even  bats 
being  highly  susceptible.  In  other  cases,  as  in  the  horse,  dogs,  cats, 
sheep,  cattle,  goats,  and  pigs,  inoculation  produces  fever  or  the  for- 
mation of  a  local  bubo  ending  mostly  in  recovery;  birds,  on  the 
other  hand,  show  a  high  degree  of  immunity. 

It  has  been  clearly  demonstrated  that  the  chief  source  of  the 
plague  in  human  beings  is  from  fleas  which  have  bitten  rats  sick  with  the 
plague.  This  has  been  particularly  proved  in  the  case  of  ship  rats, 
and  explains  why  the  plague  is  so  often  introduced  to  a  country  from 
its  seaports.  It  is  one  of  the  many  benefits  conferred  by  science  on 
mankind  that  these  facts  promise  to  rid  the  world  of  this  dangerous 
epidemic,  because  in  every  civilized  country  now  measures  are  taken 

6 


82  CLINICAL  MEDICINE 

to  exterminate  rats,  when,  as  in  the  case  of  ships,  they  are  the  means 
of  transporting  the  plague.  This  was  done  in  Cahfornia,  when  the 
plague  was  introduced  there  by  Chinese  immigrants ;  but  it  was  then 
discovered  that  squirrels  and  other  rodents  were  equally  liable  to  be 
infested.  By  such  prophylactic  measures  this  once  formidable  epi- 
demic is  nearly  extinct,  except  in  some  quarters  whose  inhabitants  are 
not  sufficiently  civihzed  to  cooperate  with  the  authorities  in  combat- 
ing the  disease.  This  has  occurred  in  India,  where  an  ignorant  oppo- 
sition on  the  part  of  the  population  has  embarrassed  the  British 
officials. 

From  what  has  been  stated,  it  is  evident  that  in  one  sense  the  plague 
is  not  contagious,  for  if  a  man  is  infected  he  can  communicate  it  to 
others  only  by  means  of  fleas.  Unsanitary  conditions  have  no  rela- 
tion to  the  occurrence  of  plague  excepting  so  far  as  they  favor  the 
multiplication  of  rats.  This  disease,  as  might  be  expected,  occurs  in 
several  forms;  the  first  is  a  mild  form,  the  pestis  minor,  in  which  the 
patient  may  not  be  ill  enough  to  seek  medical  relief,  having  only  a 
few  swollen  glands  in  the  groin,  but  he  still  is  a  serious  danger  to  others, 
as  his  urine  and  feces  will  contain  the  bacilli. 

Much  the  commonest  form  is  what  is  called  the  bubonic  plague, 
which  begins  with  headache,  backache,  stiffness  of  the  limbs,  restless- 
ness, and  great  depression  of  spirits,  with  a  fever  steadily  rising  to 
high  figures,  until  the  evening  of  the  third  or  fourth  day,  when  there  is 
a  drop  of  2  or  3  degrees,  and  then  the  fever  rises  again,  perhaps  to  a 
still  higher  point,  the  tongue  becomes  brown,  and  collapse  symptoms 
are  apt  to  supervene,  followed  by  death.  Meanwhile,  glandular  swell- 
ings of  buboes  make  their  appearance,  which  have  given  the  name  to 
the  disease.  In  over  50  per  cent,  these  buboes  appear  in  the  groin 
from  the  third  to  the  fifth  day.  If  suppuration  occurs  it  is  regarded 
as  a  favorable  feature.  Meanwhile  petechiee,  or  subcutaneous  hemor- 
rhages, rather  commonly  show  themselves,  and  are  usually  dark  in 
color  and  may  become  extensive.  It  was  this  symptom  that  gave  it 
the  name  of  black  death  in  the  Middle  Ages.  At  this  time  hemorrhage 
from  the  mucous  membrane  may  also  occur,  including  hematemesis. 
One  form  is  called  the  septicemia  plague,  which  is  merely  most  rapid  in 
its  course,  for  the  patients  may  succumb  in  three  or  four  days  before 
the  buboes  appear. 

Lastly,  there  is  the  pneumonic  plague,  one  of  the  worst  of  them  all, 
having  every  clincal  feature  of  pneumonia,  usually  lobular,  when  the 
sputum  contains  the  bacilli  in  enormous  numbers.  The  mortality 
has  been  so  great  that  in  some  places  only  3  out  of  100  survived. 


SMALL-POX  83 

Treatment.^Little  can  be  done  in  such  an  acute  disease  other  than 
by  the  local  treatment  of  the  buboes.  Ice  may  be  applied  to  them, 
and  some  good  results  are  reported  from  injection  of  bichlorid  of 
mercury.  More  hope  can  be  placed  upon  a  plague  serum  made  by 
Yersin,  but  it  must  be  employed  very  early,  if  possible  on  the  first 
day.  On  the  other  hand,  Haffkine's  serum  is  used  as  a  preventive,  by 
which,  according  to  C.  J.  Martin,  the  chances  of  subsequent  infec- 
tions are  reduced  four-fifths,  while  the  chances  of  recovery  are  two 
and  one-half  times  as  great  as  in  the  uninoculated. 

SMALL-POX 

The  origin  of  this  disease  is  of  unknown  antiquity,  for  it  evidently 
prevailed  in  China  some  centuries  before  the  Christian  era,  and  then 
spread  through  the  world  as  a  true  pandemic  for  many  centuries. 
Razes,  an  Arab  physician  of  Bagdad,  Hving  in  the  tenth  centur3^  spoke 
of  it  as  a  disease  from  which  no  one  could  be  regarded  as  exempt. 
Subsequent  writers  speak  in  the  same  strain.  For  a  long  time  it  was 
regarded  as  a  special  disease  of  children,  so  that  some  reputable  medi- 
cal writers  stated  that  those  who  apparently  escaped  infection  did 
so  because  it  was  forgotten  that  they  had  had  small-pox  in  childhood. 
Considering  its  frightful  mortality,  accompanied  by  such  repulsive 
features  during  its  course,  we  are  now  scarcely  able  to  appreciate  the 
importance  of  Jenner's  discovery  in  1796.  Not  only  does  vaccina- 
tion prevent  great  epidemics  of  small-pox,  but  it  modifies  the  disease 
when  that  occurs  in  vaccinated  persons  to  such  a  degree  as  to  cause  so 
mild  a  development  that  it  is  termed  "varioloid."  It  should  be  remem- 
bered, however,  that  a  person  with  varioloid  can  convey  the  infec- 
tion to  an  unprotected  person  in  its  severest  form.  Experience  on  a 
large  scale  has  also  demonstrated  another  important  fact,  namely, 
the  importance  of  revaccination.  Statistics  in  the  Prussian  Army, 
in  which  those  who  report  for  service  every  five  years  are  at  each 
time  revaccinated,  show  that  three  vaccinations  are  a  better  pro- 
tection than  an  attack  of  small-pox  itself.  As  revaccination  is 
compulsory  in  Germany,  the  results  are  striking.  In  Munich,  with 
a  population  of  nearly  550,000,  though  the  city  hospital  has  1320 
beds,  only  14  are  set  apart  for  small-pox.  In  Dresden,  with  a 
population  of  nearly  520,000,  there  have  been  no  small-pox  deaths 
for  ten  years. 

Owing  to  human  perversity  or  to  mental  enfeeblement  there  have 
developed,  especially  in  England,  local  epidemics  of  antivaccination, 
such  as  in  the  towns  of  Gloucester  and  Leicester,  with  the  result 


84  CLINICAL  MEDICINE 

that  small-pox  has  attacked  those  locaHties  in  epidemics  with  all  its 
pristine  vigor  and  fatahty. 

Clinical  Course. — As  we  have  remarked  before  in  treating  of  mixed 
infections,  we  have  three  separate  diseases  in  the  course  of  small-pox. 
After  an  incubation  period  averaging  from  twelve  to  fourteen  days, 
durmg  which  the  patient  seems  to  be  in  good  health,  he  is  suddenly 
attacked  with  vomiting,  accompanied  in  adults  with  a  severe  chill; 
in  children  often  with  a  convulsion  and  rapidly  developing  fever  from 
103°  to  105°  F.  Violent  headache  then  sets  in,  and  with  it  a  diagnos- 
tic backache.  No  other  infectious  disease  is  accompanied  with 
such  backache.  This  initial  attack  may,  in  a  few  cases,  be  severe 
enough  to  cause  death.  About  the  third  day  the  characteristic  erup- 
tion begins  to  appear  in  the  form  of  minute  hard  pimples,  which 
give  what  is  called  a  ''shotty  feel"  under  the  skin.  With  the  appear- 
ance of  this  eruption  the  severe  symptoms  subside  and  the  tempera- 
ture falls.  The  tongue,  which  has  been  previously  thickly  coated, 
becomes  cleaner;  the  stomach,  which  has  been  so  irritable  that  scarcely 
anything  could  be  retained,  now  not  only  becomes  quiet,  but  the 
patient  may  actually  be  hungry  and  feel  generally  so  much  better  that 
he  thinks  he  is  getting  well. 

Then  commences  the  secondary  stage  of  the  disease,  usually  about 
the  fifth  day  from  the  initial  symptoms.  The  papules  enlarge,  and  on 
the  tip  of  each  a  small,  clear  vesicle  appears,  which  greatly  facilitates 
the  diagnosis  by  being  umbilicated,  a  feature  present  in  no  other  erup- 
tion.    This  umbiHcation  consists  of  a  central  depression  in  the  vesicle. 

Soon  after  this  a  wholly  new  and  secondary  infection  of  the  pap- 
ule occurs,  because  this  latter  enlarges  and  becomes  globular,  due  to 
the  infection  of  the  eruption  by  the  streptococci  and  staphylococci, 
which  always  swarm  upon  the  skin.  As  previously  stated,  the  sur- 
geon never  ventures  upon  a  cutaneous  incision  without  the  utmost 
precautions  in  the  way  of  disinfecting  the  skin,  because  of  this  same 
infection  by  the  pyogenic  organisms  constantly  present  on  the  sur- 
face. What  the  surgeon  thus  attempts  to  prevent,  the  small-pox 
eruption  actually  causes  to  occur.  There  can  be  no  doubt  that  this 
secondary  infection  of  pyogenic  organisms  is  due  to  the  specific  action 
of  the  initial  small-pox  vesicle,  and  in  proportion  to  its  virulence  will 
be  the  secondary  invasion,  leading  in  many  cases  to  confluent  instead 
of  discrete  small-pox.  Soon  after  the  beginning  of  this  secondary 
invasion  the  whole  clinical  course  of  the  disease  is  changed.  The 
temperature  rises,  and  the  patient  presents  the  appearance  of  a 
virtual  general  septicemia. 


SMALL-POX  85 

But  a  third  and  a  more  serious  infection  occurs,  aptly  termed 
hemorrhagic,  malignant,  or  hlack  small-pox,  which  frequently  causes 
death  before  the  characteristic  eruption  appears.  We  may,  therefore, 
as  well  describe  its  symptoms  and  course  now.  The  attack  usually 
begins  with  the  same  symptoms  accompanying  the  initial  infection, 
only  they  are  more  severe,  in  the  form  of  vomiting,  and  particularly  in 
the  diagnostic  backache.  Instead  of  the  eruption,  however,  purpuric 
subcutaneous  hemorrhages  appear,  at  first  in  scattered  locations, 
but  rapidly  enlarging  and  running  together.  I  see  no  advantage  in 
dividing  up  the  initial  hemorrhagic  lesions  into  several  varieties,  be- 
cause they  all  have  in  common  the  distinctive  feature  of  subcutaneous 
hemorrhage.  Certain  parts  of  the  body,  however,  are  especially  in- 
volved, affording  an  absolutely  pathognomonic  appearance.  This  is 
marked  by  a  broad-based  triangle  with  its  apex  at  the  pubes,  or  little 
lower,  and  its  base,  including  the  whole  area  below  the  umbilicus, 
bounded  by  a  line  drawn  from  the  iliac  spines.  The  whole  surface  of 
this  triangle  assumes  a  leaden  color  which  persists  after  death.  Else- 
where there  may  be  extravasations  of  blood  under  the  skin,  such  as 
about  the  axillae,  which  occasionally  show  some  raised  papules,  but 
with  the  same  distinctive  features  of  purpuric  subcutaneous  hemor- 
rhages remaining.  The  face  may  be  swollen,  but  the  distinctive  feature 
is  hemorrhage  into  both  the  palpebral  conjunctivae  and  its  reflection 
on  the  eyeball.  This  causes  the  eyes  to  look  as  if  they  had  been  black- 
ened, an  appearance  found  in  no  other  disease.  Meantime,  the  con- 
stitutional symptoms  are  the  gravest.  The  pulse  becomes  very  weak 
and  rapid,  and  the  patients  sink  with  all  the  symptoms  of  vital  pros- 
tration, death  occurring  sometimes  within  forty-eight  hours  from  the 
beginning  of  the  disease,  while  in  other  cases  life  may  be  prolonged 
from  three  to  six  days.  It  is  remarkable  that  the  mind  is  so  Ht- 
tle  affected;  it  may  remain  clear  to  the  end.  The  only  distinctive 
change  in  the  blood  is  the  presence  of  an  intense  streptococcemia, 
the  origin  of  which  is  wholly  unknown.  One  of  the  worst  features  of 
this  form  is  that  due  to  the  absence  of  the  specific  eruption  of  small- 
pox; the  proper  diagnosis  may  not  be  made,  and,  as  the  infection  re- 
mains virulent  after  death,  many  cases  are  reported  of  persons  becom- 
ing infected  from  attending  the  funerals  of  such  patients. 

We  now  return  to  the  symptoms  marking  the  course  of  ordinary 
pustular  small-pox.  If  the  attack  is  not  very  severe  or  confluent,  the 
eruption  is  accompanied  by  considerable  swelling  of  the  skin  extending 
from  the  pustules,  swelling  of  the  cervical  lymphatic  glands,  and  with 
it  so  much  itching  that  the  patients  frequently  rupture  the  pocks 


86  CLINICAL   MEDICINE 

by  scratching  them,  producing  open,  running  sores,  which,  becoming 
further  infected,  scabbing  commences,  with  a  formation  of  more  or 
less  extensive  crusts.  If  upon  the  face,  they  are  as  thick  as  sand;  it  is  no 
advantage  to  have  them  few  and  far  between  on  the  rest  of  the  body. 
Throughout  the  third  week  the  desiccation  proceeds,  and  in  cases  of 
moderate  severity  the  secondary  fever  subsides,  but  in  others  it  may 
persist  until  the  fourth  week.  On  the  fourth  week  the  scabs  fall  off 
singly,  but  cases  have  been  reported  of  the  whole  epidermis  of  the 
hands  and  feet  separating.  The  material  of  these  crusts  when  dried 
is  highly  infectious.  The  peculiarity,  however,  is  that  the  pustules 
are  larger  and  more  ulcerated  on  the  face,  backs  of  the  wrists,  and 
hands;  in  other  words,  in  places  exposed  to  hght  and  air.  Under  the 
bed-clothes  they  are  frequently  discrete  and  much  smaller  ia  extent. 
This  fact  affords  a  hint  of  much  use  in  treatment,  as  we  shall  describe. 

In  confluent  small-pox  all  the  symptoms,  both  local  and  general, 
are  more  severe ;  the  swelling  of  the  face  and  of  the  eyelids  may  com- 
pletely obliterate  the  features,  and  the  hands  and  fingers,  which  from 
the  beginning  show  a  stiffness  in  flexion,  may  become  so  swollen  by 
the  eruption  that  the  fingers  are  kept  wide  apart,  presenting  a  repulsive 
appearance.  The  cutaneous  ulceration  is  very  apt  to  leave  its  scars 
on  the  face  for  hfe.  In  my  experience  at  the  New  York  Quarantine 
Small-Pox  Hospital  I  found  that  these  disfiguring  marks  by  scars 
could  be  prevented  by  painting  the  whole  face  with  a  saturated  solu- 
tion of  nitrate  of  silver.  Silver  nitrate  has  no  penetrating  power, 
because  it  immediately  forms  an  insoluble  albuminate  of  silver  with 
the  discharge  of  the  eruption,  which  prevents  its  deeper  penetration, 
thus  forming  a  complete  mask  which  excludes  all  hght  and  air.  When 
this  apphcation  was  made  the  patient  said  it  felt  very  cooling,  but  it 
turned  them  all  into  the  like  of  Ethiopians  from  the  blackening  of  the 
skin.  After  the  disease  had  subsided  this  protective  mask  peeled 
off,  leaving  nothing  but  the  temporary  hyperemic  appearance  of  the 
skin,  which  in  time  disappeared,  with  no  scars  remaining. 

In  malignant  small-pox,  hemorrhages  from  the  mucous  membranes 
may  take  place,  causing  hemoptysis. 

The  eruption  of  small-pox  may  occur  within  the  mouth  itself,  and 
then  cause  death  by  sudden  edema  of  the  glottis,  which  happened  to 
a  patient  of  mine  in  the  small-pox  hospital. 

In  confluent  cases  very  troublesome  carbuncles  follow  during 
convalescence.  These  are  best  treated  by  sprinkling  the  ulcers  with 
chlorate  of  potash  in  powder,  which,  although  smarting,  prevents  deeper 
extension  of  the  ulceration.     In  all  cases  of  small-pox  eruption  in  the 


SCARLET  FEVER  (SCARLATINAJ  87 

mouth  I  would  have  them  rinse  the  mouth  as  frequently  as  possible 
with  a  saturated  solution  of  chlorate  of  potash. 

Meantime,  from  the  earliest  stage  of  the  pustular  eruption,  we  should 
sustain  the  strength  of  the  patient  by  the  administration  of  12  gr.  of 
quinin  in  three  divided  doses  during  the  day,  conjoined  with  15  gr.  of 
calcium  lactate. 

SCARLET  FEVER  (SCARLATINA) 

No  disease  varies  hke  scarlatina  in  the  severity  of  its  incidence  in 
different  patients,  owing  to  their  constitutional  pecuHarities  of  un- 
known origin.  These  variations,  however,  are  not  in  the  agent  itself, 
because  the  mildest  cases  can  communicate  to  others  the  disease  in 
its  severest  forms.  Thus,  in  one  patient  scarlet  fever  can  be  so  mild 
that  its  presence  may  be  wholly  overlooked,  but  this  patient  can  com- 
municate it  to  another,  who  quickly  succumbs  to  that  form  called 
scarlatina  mahgna. 

The  agent  itself  of  scarlet  fever  is  yet  unknown,  but  by  means  of 
the  angina  of  the  throat  which  it  causes,  it  so  quickly  infects  the 
system  with  an  invasion  of  streptococci  that  by  many  writers  it  has 
been  confounded  with  them,  so  that  different  strains  of  streptococci 
have  been  erroneously  identified  as  the  primary  and  causative  agent 
of  the  disease.  Likewise  scarlatina,  like  other  acute  infections,  pre- 
vails in  an  epidemic  form  of  varying  severity  in  different  seasons. 

The  origin  of  this  disease  is  not  known  historically,  and  we  owe  to 
Sydenham,  in  1675,  its  first  differentiation  from  measles,  with  which 
it  had  been  previously  confounded.  Its  prevalence,  however,  is  chiefly 
limited  to  the  temperate  zones,  so  that  it  is  rare  in  tropical  countries. 
Practically,  the  most  important  fact  about  scarlet  fever  is  its  quick 
but  secondary  compKcation  with  the  virulent  streptococcal  infection, 
which  may  be  of  such  a  severe  type  that  the  patient  soon  succumbs 
from  a  condition  closely  resembling  hemorrhagic  small-pox,  before 
the  time  for  development  of  its  specific  eruption.  These  cases  have 
been  confounded  with  hemorrhagic  small-pox,  just  as  this  disease 
itself  has  been  mistaken  for  scarlatina.  As  we  have  shown,  both  these 
diseases  are  characterized  by  intense  strep  tococcemia. 

Symptoms. — This  disease  usually  sets  in  with  vomiting,  and  in 
some  children  with  a  convulsion.  Along  with  the  vomiting,  fever 
takes  place,  which  may  rapidly  rise  to  103°  F.  or  above.  Sore  throat 
is  simultaneously  complained  of,  and  the  throat  should  be  carefully 
inspected  then  and  afterward  at  every  visit.  Usually  in  a  few  hours 
the  eruption  appears,  first  on  the  chest  and  then  on  the  neck.      It 


iS6  CLINICAL   MEDICINE 

then  becomes  especially  marked  in  the  folds  of  the  axillas  and  after- 
ward in  the  groins.  By  the  second  or  third  day  it  has  spread  over  the 
whole  body,  from  above  downward.  One  pecuHarity  is  that,  unlike 
measles,  it  does  not  appear  on  the  face,  which,  instead,  may  show  a 
bright  flush  on  the  cheeks,  but  accompanied  by  one  symptom  which 
is  almost  pathognomonic,  and  that  is  the  ring  of  paleness  around  the 
mouth,  sometimes  accompanied  with  a  small  herpetic  eruption  at 
the  junction  of  the  Hps.  The  eruption  of  scarlet  fever,  when  t3^pical, 
is  easily  recognized  on  account  of  its  punctate  appearance.  But,  when 
general,  it  is  often  difficult  to  distinguish  it  from  numerous  other 
scarlet  rashes.  It  is  then  that  the  appearance  of  the  tongue  is  so 
distinctive.  On  carefully  examining  the  tongue,  its  tip  and  edges 
near  thereto  show  prominent  highly  injected  papillae.  The  tongue  at 
first  is  covered  by  a  white  fur,  but  through  it  appear,  projecting,  the 
inflamed  and  enlarged  papillae.  Even  when  the  tongue  has  desqua- 
mated these  papillee  remain  distinctly  swollen  and  inflamed,  giving 
origin  to  the  name  "strawberry  tongue."  The  value,  for  diagnosis, 
of  this  condition  is  because  no  other  form  of  sore  throat  is  attended 
with  such  an  appearance  of  the  tongue.  In  some  cases,  though  the 
appearances  of  the  tongue  and  throat  are  characteristic,  yet  the 
cutaneous  eruption  is  not  distinct,  so  that  the  term  "scarlatina  sine 
eruptione"  is  applied  to  such  cases.  At  the  same  time  the  tonsils 
are  greatly  inflamed  and  occasionally  covered  with  a  grayish  pelhcle 
which  may  be  confounded  with  a  diphtheric  exudation.  The 
arches  of  the  palate  Hkewise  look  very  red,  and  the  uvula  is  often 
edematous.  The  punctate  eruption  may  also  develop  on  the  roof  of 
the  mouth.  Normally,  the  skin  on  the  posterior  surface  of  the  upper 
arm  presents  numerous  papule-Uke  elevations.  These,  in  the  second 
week  of  scarlatina,  become  both  enlarged  and  inflamed,  so  as  to  con- 
stitute a  valuable  diagnostic  appearance.  In  its  further  course,  ul- 
ceration in  the  throat  with  swelHng  may  begin,  and  extend  sometimes, 
with  great  destruction  of  tissue,  to  the  contiguous  parts,  rendering 
swallowing  difficult,  and  accompanied  sometimes  with  a  regurgitation 
of  fluids  into  the  nose.  This  form  is  sometimes  called  angina  ulcerosa, 
and  is  characterized  by  persistent  vomiting.  In  more  favorable  cases, 
the  throat,  though  severely  inflamed,  is  not  subject  to  destructive 
ulceration.  When  it  is,  however,  the  lymphatic  glands  of  the  neck 
soon  become  impKcated  and  swollen,  so  that  they  may  appear  like  a 
collar  encircling  both  sides  of  the  neck.  Occasionally  suppuration 
takes  place  in  these  glands.  Meanwhile,  the  nose  becomes  involved, 
and  a  profuse  discharge  or  rhinorrhea  occurs,  which  adds  greatly  to 


SCARLET  FEVER  (sCARLATINA)  89 

the  distress  of  the  patient.  This  rhinorrhea  may  remain  infective  for 
weeks  after  the  subsidence  of  the  disease,  which  is  to  be  explained  by 
the  fact,  already  noted,  that  in  a  number  of  infections  the  patients 
continue  to  carry  about  the  germs  of  the  cUsease  for  prolonged  periods 
after  they  have  recovered  from  the  first  attack.  Thus,  after  t>phoid 
fever  the  infected  patient  may  be  the  carrier  of  typhoid  germs  even 
for  years  after  his  recovery  from  the  primary  attack.  Every  patient 
after  scarlet  fever,  with  a  discharge  from  either  the  npse  or  ears,  may 
be  capable  of  infecting  others  in  this  manner. 

Concomitant  with  the  affection  of  the  throat,  and  naturally  depend- 
ing upon  the  extension  of  the  inflammation  up  the  Eustachian  tubes, 
we  have  a  purulent  inflammation  of  the  middle  ear.  This  may  occur 
so  early  that  the  first  sign  of  it  may  be  a  purulent  discharge  from  the 
middle  ear.  The  physician  should  always  be  on  the  watch  against 
this  complication,  because  it  is  estimated  that  20  per  cent,  of  all  cases 
of  deaf  and  dumb  children  are  due  to  the  destruction  of  hearing  by  this 
scarlatinal  otitis.  One  sign  of  its  onset  is  a  sudden  rise  of  temperature 
and,  in  smaller  children,  crying  from  pain,  with  the  hand  brought  to 
the  ear. 

Incubation. — Like  other  infectious  diseases,  the  period  of  incuba- 
tion varies  in  scarlatina.  The  rule,  however,  is  that  it  is  shorter  than 
in  any  other  exanthem.  Well-authenticated  instances  of  an  incuba- 
tion period  of  only  three  days  are  numerous.  Murchison  vouches  for 
a  case,  in  his  experience,  in  which  the  incubation  period  was  only  eight- 
een hours.  On  the  other  hand,  numerous  observers,  who  pay  particu- 
lar attention  to  this  subject,  recount  cases  where  the  incubation  varied 
from  seven  to  twenty-one  days.  A  physician  may  be  naturally 
questioned  by  the  relatives  of  a  child  who  has  been  exposed  to  scarla- 
tina, how  soon  it  may  be  expected  that  he  will  show  the  first  signs 
of  an  onset.  The  reply  should  be  that,  if  a  week  has  passed,  it  is 
unlikely  then  to  develop,  but  there  are  exceptions  to  this  rule. 

The  pulse  in  scarlet  fever,  to  a  trained  observer,  is  quite  char- 
acteristic, being  not  only  small,  but  also  of  high  tension  from  the 
very  beginning,  and  hence  is  of  importance  in  diagnosis;  this  con- 
dition not  being  found  in  any  other  infective  fever.  Its  frequency 
in  children  usually  corresponds  with  the  height  of  the  fever,  and  may 
be  from  160  to  200  per  minute. 

Desquamation. — This  begins  often  with  a  peculiar  pin-hole  ap- 
pearance, coupled  with  a  very  dry  feel  of  the  skin.  On  the  face  it 
may  be  just  like  the  bloom  of  a  peach,  and  is  called  furfuraceous. 
The  desquamation  commences  in  severe  cases  in  four  or  five  days  from 


90 


CLINICAL  MEDICINE 


the  beginning  of  the  attack,  though  in  mild  cases  it  may  be  much 
later.  It  is  most  pronounced  in  the  axillae  and  the  groins,  consisting 
of  lamella  scales,  whose  size  greatly  varies  in  different  cases,  being 
smaller  in  young  children,  and  larger  in  adults.  In  the  palms  and 
soles  of  the  feet  it  occurs  the  latest  of  all,  but  also  in  the  largest  patches. 
An  early  sign  of  desquamation,  which  may  be  of  use  in  diagnosis,  is 
the  appearance  of  a  white  line  at  the  junction  of  the  pulp  of  the  finger 
with  the  nail,  looking  very  much  as  if  a  fine  superficial  incision  had 
been  made.  To  reveal  this  the  pulp  of  the  finger  should  be  pulled 
away  from  the  nail. 

Infectivity. — No  subject  is  of  so  much  importance  in  this  fever  as 
its  periods  of  infectivity.  However  early  recognized,  it  has  already 
become  infective,  though  it  usually  is  mostly  so  when  the  eruption  is 
well  out  and  the  fever  high.  Nothing,  however,  can  be  more  vexatious 
than  to  determine  when  the  patient  is  no  longer  capable  of  communi- 
cating the  infection.  The  rule  is  that  a  mild  case  should  be  isolated 
for  six  weeks,  and  severe  cases  for  double  that  length  of  time.  Cases 
with  discharge  from  the  nose  or  ear  may  remain  infective  for  three 
months.  This  question  cannot  be  decided  by  the  disappearance  of 
all  signs  of  desquamation,  as  is  shown  by  the  return  cases  of  patients 
who  have  been  discharged  from  hospitals,  apparently  quite  well,  and 
then  who  have  communicated  the  disease  to  others  at  home,  so  that 
not  even  the  most  careful  precautions  will  insure  the  cessation  of  the 
power  of  infection  for  any  number  of  weeks.  This  question  becomes 
a  very  practical  one  when  the  physician  is  asked  how  soon  after  scarlet 
fever  a  child  may  be  allowed  to  go  to  school.  The  rule  is  that  for 
mild  cases  the  isolation  need  not  be  more  than  six  weeks. 

Unlike  other  exanthemata,  scarlet  fever  in  a  patient  does  not  infect 
others  who  are  only  a  few  feet  from  him.  There  is  no  such  thing  as 
aerial  infection,  as  is  so  markedly  the  case  in  small-pox.  A  child, 
therefore,  taken  with  scarlet  fever  in  a  house,  can  be  at  once  isolated 
in  a  room  and  kept  there  during  the  whole  period  of  his  sickness, 
without  others  of  the  family  contracting  the  disease.  But  though  this 
is  happily  the  case,  unfortunately  the  contagion  may  cling  for  an 
indefinite  time  to  articles  of  clothing,  particularly  if  they  are  folded 
and  packed  away  in  trunks.  Many  cases  are  reported  in  which  such 
articles  have  infected  persons  a  year  after  they  have  thus  been  removed. 
It  should  be  remarked  that  this  agent,  like  that  of  tuberculosis,  cannot 
bear  sunlight,  and  hence  all  the  clothing  and  bedding  of  these  patients 
can  soon  be  disinfected  by  outdoor  exposure  to  the  sun.  Disinfec- 
tion of  the  room  in  which  the  patient  has  been  ill  can  be  effected 


SCARLET  FEVER  (SCARLATINA)  9 1 

only  by  tightly  closing  it  and  burning  formaldehyd,  all  persons  being 
excluded. 

The  complications  of  scarlet  fever  are  numerous.  First  we  would 
put  the  occurrence  of  pneumonia,  usually  the  bronchopneumonic 
form.  In  my  experience  20  per  cent,  of  the  patients  with  scarlet 
fever  suffer  from  this  comphcation.  I  ascribe  this  largely  to  the 
inhalation  of  infected  particles  during  the  struggles  caused  by  the 
swabbing  commonly  resorted  to  for  the  treatment  of  the  inflamed 
throat,  and  is  not  so  apt  to  occur  when  the  throat  is  douched,  as  will 
be  described  presently.  Next  to  pneumonia  comes  pleurisy,  which 
is  particularly  dangerous  in  children  on  account  of  its  leading  to  empy- 
ema. After  pleurisy  comes  arthritis,  or  so-called  scarlatinal  rheu- 
matism. This  affection  but  rarely  causes  suppuration  in  the  joints. 
If  so,  the  prognosis  of  the  case  depends  upon  whether,  as  in  pleurisy, 
the  pus  contains  streptococci,  when  the  management  of  the  case 
becomes  much  more  difficult.  Ordinarily,  the  joints  recover  without 
any  lesion  remaining.  In  scarlatinal  rheumatism,  however,  and  often 
without  it,  endocarditis  may  develop.  The  heart  is  ver>'  commonly 
affected  in  the  course  of  scarlet  fever,  being  often,  as  in  ordinary  rheu- 
matism, dilated  from  the  softening  of  its  walls,  with  the  production 
of  apex  systolic  murmurs. 

One  of  the  most  serious  sequela  is  scarlatinal  nephritis.  The  kid- 
neys may  be  congested  temporarily  at  the  beginning  of  the  fever, 
similar  to  the  same  condition  in  other  infections,  but  it  takes  on  a 
special  form,  which  occurs  late  in  the  disease,  coming  on  in  the  fourth 
week  or  afterward.  This  may  begin  as  a  glomerular  nephritis,  soon 
becoming  tubular,  and  finally  interstitial,  and  is  apt  to  occur  in  mild 
cases  as  well  as  in  severe.  An  early  sign  of  this  nephritis  is  a  general 
edema,  and,  with  it,  a  diminution  in  the  amount  of  urine  that  may 
lead  to  total  suppression,  the  urine  first  becoming  bloody.  In  my 
experience  the  prognosis  of  such  cases  is  not  necessarily  fatal,  because 
I  have  succeeded  in  re-estabhshing  the  flow  of  urine  after  it  had  been 
suppressed  for  two  days,  and  the  patient  lay  in  coma  after  one  or  more 
convulsions.  In  other  cases  the  urine  flows  freely,  and  contains  only 
-jL  of  I  per  cent,  of  albumin,  but  the  patient  may  suddenly  have  a 
convulsion  and  die.  Often  scarlatinal  nephritis  is  followed  by  chronic 
interstitial  change  in  the  kidneys,  from  which  recovery  never  takes 
place. 

Treatment. — As  regards  treatment,  I  would  put  in  the  forefront 
the  immediate  recourse  to  douching  of  the  throat.  This  cannot  be 
begun  too  early,  as  the  indication  for  it  should  be  clearly  understood, 


92  '  CLINICAL  MEDICINE 

that  the  inflammation  of  the  throat,  caused  by  the  fever,  allows  of  a 
most  free  entry  into  the  circulation  of  virulent  streptococci,  to  which 
the  chief  dangers  of  the  disease  are  due.  We  should,  therefore,  regard 
the  case  as  one  of  local  disorder  at  first,  but  quickly  leading  to  the 
most  serious  general  infection.  Therefore  it  should  be  treated  locally 
with  the  only  really  effective  measure  which  we  possess.  As  soon  as 
the  diagnosis  is  made,  I  direct  that  the  child's  mouth  should  be  kept 
wide  open  by  an  efficient  rubber  plug  inserted  between  the  front  teeth. 
A  fountain-syringe,  holding  2  gallons  of  hot  water,  is  then  sus- 
pended 5  or  6  feet  above  the  child's  head,  and  the  stream  of  hot  water 
made  to  run  through  the  tube  carried  to  the  back  of  the  tongue.  So 
long  as  the  mouth  is  kept  wide  open  the  child  cannot  swallow  any 
of  the  fluid,  nor  can  any  of  it  pass  into  the  nose.  With  the  patient 
holding  the  head  over  a  basin,  the  stream  of  water  impinges  first  on 
the  posterior  walls  of  the  pharynx,  and  returns  past  the  tonsils,  thus 
washing  them  clean  and  bringing  away  great  masses  of  throat  secre- 
tions. In  a  short  time  the  patient  experiences  such  a  relief  from  this 
douche  that  he  does  not  offer  any  resistance.  In  the  2  gallons  of 
water  2  teaspoonfuls  of  chlorate  of  potash  and  5  drops  of  oil  of 
peppermint  should  first  be  dissolved.  One  sign  of  its  efficiency  is 
that  the  swollen  glands  in  the  neck  begin  promptly  to  subside,  and 
the  painful  deglutition  owing  to  the  throat  ulcerations  similarly 
improve,  so  that  the  patient  can  take  nourishment.  From  my  ex- 
perience I  have  no  doubt  also  that  early  recourse  to  this  douche  will 
obviate  the  ears  becoming  affected.  This  douche  at  first  and  in  severe 
cases  may  be  repeated  every  two  hours. 

The  next  indication  is  to  stop  the  vomiting,  which  in  bad  cases 
may  be  very  protracted.  For  this  purpose  i  gr.  of  calomel,  rubbed  up 
with  20  gr.  of  white  sugar  and  divided  into  six  powders,  should  be  ad- 
ministered, one  powder  every  ten  minutes,  the  powder  simply  being  laid 
on  the  tongue.  I  would  repeat  this  calomel  treatment  every  day  for 
three  days  or  until  the  tongue  desquamates,  after  which  it  may  be 
discontinued.  Otherwise  the  case  may  be  left  to  nature,  for  having 
prevented  compHcations,  the  natural  powers  of  the  system  for  resist- 
ing infection  may  be  safely  relied  upon. 

In  scarlet  fever  we  particularly  note  the  great  relief  caused  by  oily 
inunctions  of  the  whole  body.  For  this  purpose  we  may  use  the 
"Hnimentum  aqua  calcis,"  applied  warm,  with  |  dram  of  oil  of  cinna- 
mon to  the  pint,  to  give  it  a  pleasant  fragrance.  This  appKcation 
greatly  allays  the  restlessness  caused  by  the  cutaneous  inflammation, 
as  well  as  reduces  temperature.     In  the  kidney  troubles,  which  in 


MEASLES  93 

my  experience  do  not  occur  if  the  douching  has  been  thoroughly  em- 
ployed, diminution  and  suppression  of  urine  is  best  treated  by  i  to  2 
gallons  of  normal  saline  solution  poured  into  the  rectum  by  means  of 
Kemp's  rectal  irrigator,  the  best  instrument  for  all  forms  of  deficient 
renal  action  that  we  possess.  Should  suppression,  however,  already 
have  taken  place,  counterirritation  should  be  apphed  in  front,  over 
both  kidneys,  in  a  way  suggested  by  Brown-Sequard.  Tablespoons 
are  immersed  in  boiling  hot  water  and  then  quickly  touched  on  the 
abdominal  surface  in^three  or  four  places  on  each  side.  I  once  restored 
a  patient  who  had  had  suppression  for  two  days,  and  then  a  convulsion, 
after  which  he  was  pronounced  dead  by  a  physician  who  had  been 
called  in,  but  on  the  last  appKcation  of  the  hot  spoons  he  opened  his 
eyes  and  soon  passed  some  bloody  urine.  Fifteen  years  afterward  he 
sent  me  his  wedding  cards. 

MEASLES 

Measles  is  due  to  a  highly  contagious  infection  which  prevails  over 
the  whole  world.  Its  causative  agent  has  not  yet  been  identified,  nor 
do  we  know  of  its  first  appearance  in  history,  but  its  first  introduction 
into  certain  parts  of  the  world  is  often  very  definitely  known.  It  is 
highly  communicable. 

Clinical  Course. — Some  days  before  the  rash  appears  on  the  sur- 
face there  has  already  occurred  very  characteristic  symptoms  of 
coryza,  suffusion  of  the  eyes,  lacrimation,  nasal  catarrh,  and  acute 
bronchitis.  Previous  to  the  skin  eruption  an  eruption  also  takes  place 
in  the  mouth,  which  is  very  distinctive,  consisting  of  reddish  spots, 
tipped  by  a  minute  bluish-white  exudation,  called  after  Dr.  Koplik, 
of  New  York,  who  gave  its  first  accurate  description,  though  it  had 
been  noted  before  by  other  observers.  These  spots  are  found  espe- 
cially upon  the  buccal  mucous  membrane  and  on  the  inside  of  the  Hps. 
They  generally  appear  two  or  three  days  before  the  eruption,  though 
occasionally  not  until  the  cutaneous  eruption  appears.  They  thus 
constitute  a  valuable  means  of  diagnosis,  because  measles  is  highly 
communicable  during  the  period  of  its  catarrhal  symptoms,  and  hence 
the  disease  spreads  while  it  is  not  yet  suspected  until  the  rash  comes 
out  on  the  face.  Measles  is  probably  carried  by  the  air,  but  not  com- 
monly, differing  thus  altogether  from  small-pox.  It  does  not,  like 
scarlet  fever,  infect  a  room  or  its  belongings,  susceptible  children  being 
allowed  safely  to  enter  an  apartment  where  a  patient  has  been  sick 
with  it  shortly  before. 

The  period  of  incubation  of  measles  may  be  set  down  as  about 


94  CLINICAL   MEDICINE 

eleven  or  twelve  days  after  exposure,  and  then  begins  with  the  symp- 
toms of  a  bad  cold.  The  rash  first  appears  as  minute  pimples  at  the 
roots  of  the  hair.  These  coalesce  in  the  form  of  very  characteristic 
crescentic  reddish  spots,  which  then  rapidly  spread  to  the  temples, 
to  the  rest  of  the  face,  behind  the  ears,  and  then  progressively  over  the 
trunk  and  down  the  lower  extremities,  appearing  upon  both  the  flexor 
and  extensor  surfaces,  and  well  marked  on  the  backs  of  the  wrists,  the 
palms  of  the  hands,  and  the  soles  of  the  feet.  At  first  the  spots  are  of 
rose-red  color,  but  in  time  become  less  bright,  shading  into  purple. 
In  some  cases  the  papules  are  larger  and  have  a  distinctly  shotty  feel, 
so  that  they  may  be  mistaken  for  small-pox.  A  very  dangerous  form 
of  measles  is  characterized  by  actual  hemorrhage  into  the  skin,  which 
so  darkens  the  spots  as  to  give  rise  to  the  term  black  measles.  In 
different  epidemics  it  may  be  either  very  transient  or  unduly  prolonged. 
The  eruption  usually  appears  on  the  third,  fourth,  or  fifth  day  after  the 
catarrhal  symptoms  begin.  Eruption  is  more  intense  if  the  patient 
is  kept  warm  in  bed.  It  is  delayed  by  external  cold,  and  is  hastened  in 
its  appearance  by  a  warm  bath.  Occasionally,  in  weakly  children,  the 
rash  fades  from  heart  failure,  when  hot  baths  and  internal  stimulants 
should  be  immediately  resorted  to.  The  usual  time  for  the  eruption 
to  appear  is  the  fourth  day  after  the  first  catarrhal  symptoms.  At 
this  time  there  is  apt  to  be  marked  photophobia,  and  this  affection  of 
the  eyes  may  persist  for  weeks.  Epistaxis  may  also  occur  about  the 
third  or  fourth  day  after  the  eruption. 

So-called  mahgnant  measles,  which  we  have  already  referred  to,  is 
fortunately  rare.  In  this  form  the  eruption  becomes  hemorrhagic, 
accompanied  by  high  temperature,  death  being  sometimes  preceded  by 
a  rise  to  107°  or  109°  F.  Any  sudden  rise  in  temperature  a  day  or  two 
after  the  eruption  is  out  may  be  regarded  as  an  indication  of  some  com- 
plication, such  as  pneumonia  or  otitis  media.  The  duration  of  the 
fever  after  the  eruption  varies,  but  the  rule  is  that  it  begins  to  decHne 
after  the  third  day,  and  reaches  normal  by  the  end  of  the  week,  in 
uncompHcated  cases.  Desquamation  follows  nearly  every  case  of 
measles,  but  may  be  so  slight  as  to  escape  detection.  It  usually  consists 
of  small  bran-like  scales  and  lasts  from  one  to  two  weeks. 

The  complications  of  measles  are  numerous,  the  most  important 
being  bronchopneumonia,  which  is  present  in  every  fatal  case.  Next 
to  pneumonia  is  pleurisy,  which,  however,  is  not  so  serious  as  pleurisy 
in  scarlet  fever.  The  throat  in  measles  is  very  red  and  inflamed,  the 
inflammation  often  extending  to  the  larynx,  with  a  croupy  cough. 
It  is  due  to  this  condition  of  the  throat  that  otitis  media  develops,  but 


MEASLES  95 

not  at  all  as  commonly  as  in  scarlet  fever.  The  next  complication 
is  diarrhea,  which  occurs  very  often,  and  early  in  the  disease.  One 
pecuHarity,  however,  of  the  change  in  the  skin  produced  by  measles 
is  a  tendency  to  gangrene  of  the  affected  surface,  such  as  does  not  occur 
in  any  other  exanthem.  I  have  known  of  2  cases  of  fatal  gangrene 
in  children  caused  by  the  apphcation  of  a  mustard  poultice  during 
the  initial  stage  of  bronchitis.  Some  disturbances  of  the  nervous  sys- 
tem occur  immediately  after  measles,  but  no  more  than  in  other  exan- 
themata. 

Treatment. — The  mortality  from  measles  themselves,  in  famiUes 
well  housed  and  with  abundant  air  space,  is  so  shght  that  a  physician 
might  regard  this  as  a  comparatively  trivial  disease.  In  a  long 
general  family  practice  I  can  remember  only  i  death  from  measles, 
but  the  United  States  census  report  states  that  nearly  13,000  persons 
died  from  measles  in  one  year,  and  in  England  the  mortahty  is  greater 
than  in  scarlet  fever.  But  the  reasons  for  this  are  that  the  severity 
of  an  epidemic  of  measles  is  greatest  in  crowded  tenements  or  in  hos- 
pitals for  contagious  diseases.  In  such  circumstances  measles  acquire 
an  increased  virulence;  the  more  crowded  and  confined  the  quarters, 
the  worse  the  disease,  and  in  all  cases  the  mortahty  is  not  due  so 
much  to  measles  as  to  its  compHcations.  It  is  necessary  to  take 
the  initial  bronchitis  in  hand  at  once  for  the  purpose  of  rendering 
the  secretion  very  fluid  and  easily  expectorated.  For  this  I  know 
of  no  agent  equal  to  my  linseed  oil  mixture  referred  to  on  page  316. 
It  should  be  remembered  that  the  bronchial  tubes,  whether  large 
or  small,  should  contain  nothing  but  air.  Every  Hquid  secretion, 
therefore,  in  these  tubes  is  virtually  a  foreign  body,  and  if  the  secre- 
tion be  viscid  and  thus  difficult  of  removal,  this  fact  suffices  to  explain 
the  supervention  of  pneumonia  in  the  lobules  supplied  by  the  occluded 
bronchioles.  As  young  children  are  very  deficient  in  the  power  of 
expectoration,  this  explains  why  general  bronchopneumonia  is  so 
commonly  fatal  in  measles. 

From  I  to  2  teaspoonfuls  of  my  linseed  oil  mixture  should  be  given 
every  three  hours  to  a  child  under  five  years  of  age,  and  the  cough 
will  be  relieved  by  the  addition  of  yV  gr.  of  heroin.  In  other  cases 
the  hquor  ammonias  acetatis  may  be  given  or  sweet  spirits  of  niter 
with  10  to  15  drops  of  paregoric.  When  the  cough  is  croupy,  steam 
inhalations,  with  y  q-  of  molasses  to  the  quart  of  water,  should  be  kept 
up,  for  this  is  the  best  way  of  allaying  laryngeal  irritation,  the  steam 
being  conducted  under  a  tent  over  the  child's  bed.  Lastly,  the  skin 
should  be  well  oiled  twice  a  day  with  the  liniment  of  aqua  calcis,  as 


96  CLINICAL  MEDICINE 

recommended  for  scarlet  fever.  The  eyes,  should  be  carefully  attended 
to  by  appropriate  lotions  of  boric  acid,  while  the  edges  of  the  eyelids 
are  kept  from  adhering  by  using  a  mixture  of  three  parts  of  unguentum 
hydrargyrum  ammoniatum  to  i  part  of  oxid  of  zinc  ointment.  So 
long  as  there  is  photophobia  the  patient  should  be  kept  in  a  darkened 
room.  Should  epistaxis  occur,  the  child  should  be  given  5  gr.  of  chlo- 
rid  of  calcium,  which,  on  account  of  its  irritant  taste,  is  given  three 
times  a  day  in  syrup.  The  diarrhea  of  measles  is  best  controlled  by 
calomel  in  the  same  way  as  prescribed  for  the  diarrhea  of  scarlet  fever. 

RUBELLA  OR  GERMAN  MEASLES 

This  is  a  mild  exanthem,  whose  specific  characteristic  is  shown  by 
its  not  preventing  the  subsequent  development  of  scarlet  fever  or 
measles,  to  both  of  which  diseases  its  eruption  has  some  resemblance. 
Rubella  is  characterized  by  a  rash,  which  in  one  part  of  the  body  may 
resemble  scarlet  fever,  and  in  another  part  may  resemble  measles. 
Its  only  distinctive  characteristic  is  found  in  the  swelhng  of  the  post- 
cervical  glands,  which  may  be  as  large  as  a  walnut,  but  it  never 
shows  the  severe  angina  of  scarlet  fever  or  the  catarrhal  symptoms 
of  measles.  Its  incubation  period  is  very  irregular,  ranging,  according 
to  some  writers,  from  one  day  to  four  weeks.  The  rule  is  that  the 
fever  is  very  slight,  and  so  also  the  constitutional  symptoms.  In  epi- 
demics it  may  become  very  contagious,  and  it  almost  always  prevails 
in  an  epidemic  form.  It  calls  for  no  special  treatment  except  segre- 
gation and  rest  in  bed. 

TYPHUS  FEVER 

I  became  too  well  acquainted  with  typhus  fever  when  I  was  phys- 
ician of  the  New  York  Quarantine,  for  the  immigrants  were  chiefly 
Irish,  and  came  over  in  slow-sailing  vessels.  I  sometimes  boarded 
these  ships,  and  can  never  forget  the  foul  odors  between  decks,  where 
the  immigrants  were  huddled  together.  These  conditions  were  most 
efficacious  in  causing  the  worst  epidemics  of  this  disease.  In  the 
year  previous  to  my  accepting  the  position  the  health  officer  himself 
and  five  physicians  of  the  hospital  died  from  contracting  typhus.  It 
was  then  especially  prevalent  among  physicians,  so  that  two  years 
afterward,  when  I  was  connected  with  Bellevue  Hospital,  five  of  its 
house  staff  succumbed  to  its  infection. 

Historically,  it  was  one  of  the  worst  scourges  among  men,  espe- 
cially in  the  camps  of  armies,  while  now  it  is  well-nigh  extinct,  particu- 
larly in  the  United  States,  due  to  the  recognition  of  its  extreme  con- 


TYPHUS    FEVER  97 

tagiousness,  which  leads  at  present  to  the  prompt  isolation  of  the 
patients.  It  is  not  only  the  sick  who  are  dangerous,  but,  like  small- 
pox, one  can  give  the  infection  to  others  from  its  lurking  in  the 
clothes.  The  case  is  mentioned  of  a  whole  court  of  judges  and  their 
attendants  contracting  it  from  prisoners  brought  before  them  from 
their  jails.  One  of  the  names  of  this  fever,  therefore,  used  to  be  jail 
fever.  It  is  a  curious  illustration  of  the  prolonged  confusion  of  this 
fever,  with  the  totally  different  disease  of  typhoid  fever,  that  the 
term  ''typhoid"  means  that  it  is  like  unto  typhus,  whereas  no  two 
diseases  could  be  more  distinct.  After  I  came  to  New  York  City 
from  the  Quarantine  I  found  myself  in  controversy,  at  a  meeting  of 
the  New  York  County  Medical  Society,  with  a  majority  of  the  speakers, 
who  claimed  that  typhoid  fever  was  simply  abdominal  t}q3hus.  It 
would  be  well,  on  that  account,  to  change  the  name  of  typhoid  to 
that  of  enteric  fever,  as  it  is  frequently  called  in  England. 

Symptoms. — A  review  of  the  most  characteristic  symptoms  of 
these  two  fevers  is  arranged  in  parallel  columns  for  illustration: 

Typhus.  Typhoid. 

Highly  contagious.  Not  contagious. 

Onset  rapid.  Onset  gradual. 

Subsides  usually  by  crisis.  Subsides  by  lysis. 

Eruption  may  be  as  early  as  the  second  Eruption  late,  discrete;  disappearing  and 
day,  and  may  be  complete  in  forty-  reappearing  in  other  places, 

eight  hours;  no  fresh  eruption  after 
the  completion  of  the  first  appear- 
ance. 

Eruption  soon  becomes  hemorrhagic  and  Eruption   neither  hemorrhagic    nor  pete- 
then  petechial.  chial. 

No  characteristic  internal  lesions.  Very  characteristic  lesions  in  the  intestine. 

Duration  not  much  above  two  weeks.  Duration  four  weeks. 

No  relapses.  Relapses  about  one  in  five. 

Causative  agent  unknown.  Causative  agent  Eberth's  bacillus. 

The  onset  of  this  fever  is  usually  sudden  and  marked  by  a  rapid 
development  of  muscular  and  general  prostration,  so  that  it  is  un- 
common for  a  patient  to  continue  up  and  about  on  the  second  day. 
Eesides  the  headaches,  there  are  the  general  achings  in  the  back  and 
Hmbs  characteristic  of  most  acute  febrile  infections,  consisting  of  chills, 
headache,  and  frequently  nausea,  the  fever  rising  to  103°  or  105°  F. 
The  face  is  very  flushed  and  the  conjunctivae  congested.  The  tongue 
is  dry  and  tremulous.  Delirium,  so  common  afterward,  does  not  occur 
a,t  the  beginning,  except  in  alcohohcs.  The  pulse,  in  contrast  to  ty- 
phoid fever,  is  usually  rapid  at  the  beginning  and  not  dicrotic.  The 
abdomen  does  not  show  any  particular  features,  except  that  the 
7 


98  CLINICAL  MEDICINE 

spleen  is  early  enlarged.  About  the  third  to  the  fifth  day  the  eruption 
appears,  first  on  the  abdomen,  then  on  the  chest  and  shoulders,  then 
over  the  back  and  extremities.  The  face  becomes  very  much  reddened 
and  swollen,  but  rarely  shows  the  characteristic  eruption,  and  the 
palms  of  the  hands  and  soles  of  the  feet  usually  escape  also.  The 
rash  usually  requires  from  forty-eight  to  seventy-two  hours  for  its 
full  development.  With  the  development  of  the  eruption  delirium 
sets  in,  and  may  rapidly  become  maniacal.  The  expression  then  is 
characteristic,  the  eyes  being  like  those  of  one  under  high  excitement. 
In  this  state  the  patients  have  to  be  watched,  lest  they  injure  them- 
selves or  others.  During  this  period  the  eruption  changes,  a  certain 
number  of  spots  becoming  petechial,  and,  with  this,  the  eruption  be- 
comes much  more  prominent,  and  always  a  dirty  bluish  color.  In 
the  second  week  the  active  delirium  subsides,  and  the  patient  Hes 
in  a  stupor  or  coma  vigil,  with  intense  prostration,  the  eruption  mean- 
while changing  in  color,  from  the  increase  in  subcutaneous  hemor- 
rhage, until  it  becomes  a  characteristic  dusky  hue,  the  temperature  con- 
tinuing high,  from  104°  to  105°  F.  or  over,  the  pulse  becoming  progres- 
sively more  feeble.  Toward  the  latter  part  of  the  week,  if  the  prog- 
ress is  favorable,  the  temperature  drops  rapidly.  If  the  defervescence  is 
prolonged,  complications  must  be  looked  for.  The  cutaneous  petechiae 
outlast  the  defervescence  and  may  remain  as  brownish  spots.  As  re- 
covery sets  in,  sweating  develops.  Recovery  may  be  quite  active, 
with  returning  appetite.  On  the  other  hand,  death  may  occur  in  the 
first  week,  with  severe  toxic  symptoms.  It  is  rare  for  death  to  occur 
after  the  second  week.  The  temperature,  which  has  continued  high, 
begins  at  the  middle  and  close  of  the  second  week  to  drop,  often  rapidly. 
In  certain  fatal  cases  hyperpyrexia  occurs  before  death,  the  temperature 
reaching  108°  or  109°  F.  The  pronounced  nervous  symptoms  char- 
acteristic of  the  complaint  are  of  purely  toxic  origin  and  not  accom- 
panied by  organic  changes.  Early  severe  delirium  is  unfavorable. 
Muscular  tremor  is  very  common,  without  the  characteristic  tremor  in 
typhoid  of  the  tongue,  often  marked  by  subsultus;  occasionally  dis- 
tressing muscular  cramps  develop.  Epistaxis  is  uncommon,  but  there 
may  be  a  catarrhal  condition  of  the  respiratory  tract,  with  a  dry  cough 
and  altered  voice.  The  laryngitis  may  be  accompanied  by  actual 
ulceration  of  the  cartilages.  The  supervention  of  any  form  of  pneu- 
monia, in  typhus,  is  serious.  All  the  signs  of  myocardial  weakness 
may  develop,  the  first  sound  of  the  heart  changes,  and,  in  bad  cases,  is 
actually  inaudible.  The  red  corpuscles  show  no  decline,  but  there  is 
generally  moderate  leukocytosis.     A  high  leukocytosis,  like  that  of 


DIPHTHERIA  99 

30,000,  is  unfavorable,  but  it  is  said  that  the  persistence  of  eosino- 
phils is  a  good  omen.  The  tongue  becomes  dry  and  even  fissured 
with  the  progress  of  the  disease,  while  sordes  accumulate  about  the 
teeth  and  lips.  Gastric  and  intestinal  disturbances  are  both  of  Uttle 
account  compared  to  what  they  are  in  typhoid.  The  kidneys  are  not 
affected  more  than  is  common  in  all  severe  febrile  conditions. 

As  usual  with  all  febrile  infections,  there  may  be  different  grades, 
some  cases  of  typhus  being  very  mild,  but  ambulatory  typhus  is 
unknown.  Typhus  fever  in  childhood  is  not  very  common,  and  the 
course  of  the  disease  is  usually  milder.  More  males  than  females  are 
attacked,  from  difference  in  the  exposure  of  men  to  the  infection. 
The  older  the  patient,  the  more  serious  the  outlook.  Fat  persons,  as 
in  other  febrile  infections,  are  bad  subjects.  Rarely  will  typhus  attack 
tuberculous  patients,  and,  as  a  membrane  is  not  uncommon  in  the 
throat  in  typhus,  it  is  possible  to  be  taken  for  diphtheria.  Another 
distinction  between  typhus  and  typhoid  is  that  neither  of  those  dis- 
eases protect  against  the  other,  for  patients  with  typhoid  have  been 
mistakenly  sent  into  typhus  wards  and  there  have  contracted  that 
fever.  Typhus  fever  invariably  increases  in  gravity  according  to  the 
limitation  of  air  space.  Alcoholism  is  also  unfavorable,  as  well  as 
advanced  age,  already  referred  to. 

Prophylaxis  is  of  special  importance  in  the  cases  of  physicians  and 
nurses  in  hospitals.  The  high  mortahty  of  this  class  is  largely  due  to 
overwork,  predisposing  to  the  fever. 

Treatment. — As  to  treatment,  we  have  no  specific  against  this 
infection,  and  our  object  should  be  to  sustain  the  patient  until  the 
relatively  early  advent  of  the  crisis.  If  the  patient  is  in  a  comatose 
condition,  great  care  should  be  taken  lest  he  choke  while  being  fed.  He 
should  be  often  turned  from  side  to  side  to  lessen  the  danger  of  h3^o- 
static  congestion,  and  the  mouth  should  be  frequently  cleansed  by 
washes  of  chlorate  of  potash. 

This  serious  fever  is  now  so  nearly  extinct,  both  in  America  and  in 
Europe,  where,  as  in  Ireland,  it  used  to  prevail  with  great  mortality, 
that  but  few  physicians  will  now  ever  see  a  case. 

DIPHTHERIA 

This  formidable  disease  is  of  no  recent  origin,  for  it  is  plainly  de- 
scribed in  ancient  writings,  such  as  that  of  Aretasus  in  the  year  in 
A.  D.,  and  that  of  Galen  in  i8o  A.  D.,  who  performed  tracheotomy  for 
a  membranous  exudate  in  the  trachea.  From  the  beginning,  however, 
it  has  shown  much  variation  in  its  prevalence,  which  may  be  extensive 


lOO  CLINICAL  MEDICINE 

at  one  time,  and  then  die  out  for  long  periods,  in  a  given  locality. 
Thus  in  Boston  it  prevailed  to  such  an  extent  in  the  years  1735-36 
that  the  city  authorities  had  a  conference  with  the  medical  profession 
as  to  limiting  its  ravages.  In  177 1  a  severe  epidemic  in  New  York  was 
carefully  observed  by  Dr.  Samuel  Bard,  who  wrote  a  treatise  on  the 
subject,  describing  it,  hke  the  Boston  physicians,  as  putrid  sore  throat. 
But  when  I  came  to  the  city  of  New  York  in  1861  many  physicians 
doubted  its  existence,  and  uniformly  spoke  of  membranous  croup,  the 
reason  for  this  being  that  its  now  common  accompaniments  of  ulcera- 
tion, paralysis,  and  affections  of  the  heart,  causing  sudden  death,  were 
almost  unknown,  or  at  least  not  ascribed  to  it. 

It  was  really  not  until  Klebs  and  Loffler  identified  it  in  1884  with 
a  minute  bacillus,  which  now  goes  by  their  name,  that  it  was  properly 
recognized  as  a  specific  disease. 

It  cannot  be  too  clearly  emphasized  that  at  first  this  disease  is  a 
purely  local  infection  of  some  mucous  membrane,  because  the  bacillus 
itself  rarely  enters  the  blood.  It  spreads,  however,  over  the  mem- 
brane, where  it  secretes  one  of  the  most  virulent  of  poisons,  which,  by 
absorption  into  the  circulation,  causes  its  different  effects.  We  dwell 
upon  this  fact  here  because  of  its  practical  importance,  indicating 
that  it  ought  to  be  washed  away  by  local  douching  before  its  mem- 
branes are  sufficiently  developed  to  generate  this  special  virus.  This 
may  be  done  by  the  throat  douche  which  we  have  described,  but  which, 
unfortunately,  cannot  be  so  effectively  used  if  the  seat  of  the  exudation 
is  in  the  nares.  Diphtheria  throws  off  its  toxins  in  the  same  way  that 
the  tetanus  bacillus  infects  locally,  and  there  generates  its  toxin,  which 
then  enters  the  blood.  Unfortunately,  these  two  are  the  only  agents 
so  far  known  whose  toxins  are  set  free  in  the  circulation.  They  differ, 
therefore,  in  this  respect  from  other  infections  like  the  bacilli  of  ty- 
phoid fever,  which  hold  their  toxins  tightly  within  the  cells,  and  are, 
therefore,  called  endotoxins,  for  against  the  toxins  both  of  diphtheria 
and  of  tetanus  we  have  a  recourse  to  chemical  antidotes  generated 
in  the  body,  called  antitoxins.  When  used  early  in  the  case  of  diph- 
theria, antitoxin  has  materially  diminished  the  mortality  of  the  infec- 
tion. An  antitetanus  toxin  has  also  been  discovered,  but  it  must  be 
used  so  early  in  the  disease  that  its  efficacy  is  not  equal  to  that  of  the 
diphtheria  antitoxin. 

Though  the  primary  development  of  its  membrane,  on  the  tonsil, 
for  example,  may  not  be  more  than  |  inch  square,  yet  that  may  be 
sufficient  to  cause  death.  The  rule,  however,  is  that  the  membrane 
rapidly  extends  from  its  first  seat,  and  grows  thicker  as  well  as  wider, 


DIPHTHERIA  lOI 

due  to  the  formation  of  an  abundant  fibrinous  exudation  from  the 
blood.  Mixed  with  this  fibrinous  material  there  is  another  deposit 
of  a  hyaline  character.  Soon,  dipping  deeply  into  the  subjacent  tissue, 
this  exudation  causes  ulceration,  and  from  this  ulcerated  surface  great 
quantities  of  streptococci  enter  into  the  circulation.  This  secondary 
infection  may  in  time  mask  that  of  the  diphtheria  agent  itself,  and 
against  it  the  diphtheria  antitoxin  may  be  of  no  avail,  because  the 
antitoxin  is  specific  against  the  diptheria  bacillus  only.  Another 
fact  should  also  be  noted,  that  when  this  ulceration  is  deep,  as  well  as 
extensive,  the  diphtheria  bacillus  itself  may  gain  entrance  into  the 
blood,  and  thus  account  for  the  presence  of  this  bacillus  in  the  blood, 
quite  independent  of  the  presence  of  its  toxin — all  of  which  is  another 
proof  that  the  sooner  the  antitoxin  is  used  the  better. 

Antitoxin. — The  discovery  of  the  diphtheria  antitoxin  is  one  of 
the  most  important  in  modern  medicine.  It  was  led  up  to  by  pro- 
longed investigations  by  Behring,  Roux,  Sidney  Martin,  Chaillou, 
and  Yersin.  This  antitoxin  is  present  in  the  serum  of  animals  ren- 
dered immune  to  the  disease  by  the  injection  of  many  repeated  small 
doses  of  the  toxin.  The  horse  is  now  practically  the  only  animal 
whose  serum  is  used  for  this  purpose  after  he  has  been  receiving 
subcutaneous  injections  of  the  toxin  for  three  months.  At  the  end 
of  that  time  a  little  blood  is  drawn,  and  the  serum  tested  to  determine 
the  degree  of  antitoxic  power  which  it  has  acquired.  A  somewhat 
arbitrary  standardization  of  the  antitoxic  power  is  then  adopted, 
taking  for  the  immunity  unit  the  amount  of  antitoxin  serum  which 
will  neutraHze  a  hundred  times  the  minimum  lethal  dose  of  toxin,  but 
as  this  varies,  the  dose  is  estimated  by  units  and  not  by  definite  quan- 
tities. The  best  place  for  injecting  antitoxin  is  near  the  angle  of  the 
scapula.  The  serum  should  be  injected  slowly,  and  the  swelling  caused 
by  it  should  be  allowed  to  subside  without  rubbing.  The  dose  should 
be  regulated  altogether  by  the  conditions  of  each  case.  If  there  is 
marked  congestion  of  the  throat,  even  if  there  be  no  membrane,  4000 
units  should  be  given,  and  then  at  the  end  of  four  or  six  hours  a  second 
dose  of  the  same  size  should  be  administered,  and  this  should  be  re- 
peated until  the  membrane  has  disappeared.  If  there  be  very  exten- 
sive membrane  when  the  patient  is  seen  for  the  first  time,  8000  or 
10,000  units  should  be  given,  repeated  every  four  or  six  hours  until 
the  membrane  begins  to  shrivel,  with  the  diminution  of  the  nasal 
discharge  or  other  signs  of  general  improvement.  If  a  patient  when 
first  seen  has  very  extensive  membrane  and  a  profuse  discharge  from 
the  nose,  cold,  clammy  hands  and  feet,  and  a  feeble  pulse,  20,000  units 


I02  CLINICAL    MEDICINE 

of  antitoxin  may  be  at  first  administered,  and  then  10,000  more,  and 
then  again  10,000  more.  Some  apparently  hopeless  cases  have  been 
saved  by  the  administration  of  50,000  units,  given  in  the  same  divided 
doses  above  mentioned. 

The  effect  of  the  use  of  antitoxin  in  diminishing  the  death-rate  from 
diphtheria  is  shown  in  the  case  of  the  city  of  Boston.  For  the  twenty 
years  from  1875  to  1904  the  average  ratio  of  mortahty  per  10,000  of 
the  population  was  14.46,  but  while  antitoxin  was  used,  from  1895 
to  1904  inclusive,  the  ratio  was  6.42 — a  diminution  of  more  than 
one-half.  Such  a  lessening  of  mortahty  was  demonstrated  in  similar 
statistics  fohowing  the  use  of  antitoxin  in  Europe,  America,  and  Aus- 
traha,  and,  therefore,  could  not  be  attributed  to  any  local  influences. 
For  a  time  opposition  was  based  upon  the  unsatisfactory  results  in  the 
administration  of  Koch's  tubercuhn,  but  there  is  no  parallel  between 
these  two  forms  of  serum  therapy,  and  now  the  verdict  of  the  profession 
is  unanimous  that  we  have  no  agent  so  effective  against  diphtheria  as 
the  early  and  proper  administration  of  the  diphtheria  antitoxin.  The 
failure  of  these  serums  at  the  beginning  was  entirely  due  to  too  small 
doses  being  employed,  and  as  there  is  practically  no  serious  injury  fol- 
lowing these  injections,  there  can  scarcely  be  any  danger  from  large 
doses.  Following  the  hypodermic  use  of  the  antitoxin  temporary 
cutaneous  eruptions  may  take  place.  These  cutaneous  eruptions  may 
appear  either  in  the  form  of  erythema  or  urticaria.  While  these  may 
occasion  temporary  annoyance,  they  have  no  permanent  serious  effects. 
The  liabihty  to  these  eruptions  differs  according  to  the  antitoxin  used, 
and  is  least  in  those  preparations  which  are  of  the  greatest  efficiency. 
It  must  be  admitted,  however,  that  death  has  followed  after  the  use 
of  this  injection  in  patients  who  have  been  subject  to  true  asthmatic 
seizures.  We  have  no  explanation  of  this  prochvity  to  react  so  inju- 
riously to  this  agent,  but  enough  has  been  observed  to  allow  of  pre- 
caution in  chronic  asthmatics. 

Diphtheria  of  the  eye  may  be  caused  in  a  physician  attending  a 
case  by  a  pellet  being  directly  coughed  from  the  patient  into  his  eye. 
Diphtheria  of  the  eye  is  thus  described  by  Dr.  John  H.  McCullom,  in 
Osier's  "Modern  Medicine,"  page  414,  vol.  ii: 

"Diphtheria  of  the  eye,  or  diphtheric  conjunctivitis,  is  not  infre- 
quent. It  is  sometimes  caused  by  the  secretions  of  the  throat  of  the 
patient  being  coughed  into  the  eyes  of  the  attendant,  particularly  in 
tracheotomy  cases.  The  more  common  cause  is  auto-inoculation 
from  the  nasal  discharge,  Diphtheria  of  the  eye  commences  with  a 
sb'ght  congestion,  which  rapidly  increases,  and  is  followed  by  the  for- 


DIPHTHERIA  IO3 

mation  of  a  distinct  membrane  which  has  a  grayish-white  appearance, 
a  Httle  different  from  that  of  the  membrane  in  the  throat.  The  proc- 
ess goes  on  very  rapidly,  so  that  at  the  end  of  twenty-four  or  thirty- 
six  hours  the  eye  is  so  inflamed  that  it  is  impossible  to  separate  the 
eyelids.  There  are  two  varieties  of  diphtheria  of  the  eye — the  super- 
ficial and  the  deep — either  of  which  is  very  serious.  In  the  former 
the  eye  is  invariably  lost,  in  the  latter  it  is  sometimes  saved.  There 
is  a  considerable  amount  of  constitutional  disturbance  and  usually 
severe  pain.  The  rapidity  with  which  the  disease  advances  is  very 
great,  so  that  sometimes  in  forty-eight  hours  the  eye  is  hopelessly 
destroyed.  In  the  milder  attacks,  even  when  the  eye  is  saved,  the 
morbid  process  continues  for  six  or  seven  days.  If  the  attack  comes 
on,  which  is  not  infrequent,  during  the  course  of  measles,  the  proba- 
bility of  saving  the  eye  is  very  slight.  The  general  condition  of  the 
patient  is  also  an  important  factor  in  the  prognosis." 

Virulence. — From  all  which  precedes,  it  is  evident  that  the  specific 
virus  of  diphtheria  is  one  of  the  most  virulent  of  known  poisons.  This 
is  due  to  its  well-nigh  universal  proteolytic  or  tissue-dissolving  prop- 
erty. Every  important  organ  of  the  body  can  have  its  tissues  locally 
destroyed  by  it.  Such  changes  appear  the  same  in  character  in  the 
liver  or  the  kidneys,  but  the  most  marked  changes  occur  in  the 
muscular  and  nervous  tissues,  and  may  involve  the  walls  of  the  heart 
and  its  nerve  gangha.  Moreover,  death  is  ascribed  to  a  similar  de- 
generation in  the  cardiac  branches  of  the  vagus  or  pneumogastric 
nerve,  producing  heart  paralysis.  This  is  one  reason  why  a  patient 
should  be  carefully  watched  during  his  seeming  convalescence.  So 
long  as  the  pulse  remains  weak  and  irregular,  it  is  not  safe  for  the 
patient  to  make  any  sudden  exertion ;  even  sitting  up  in  bed  has  been 
known  to  cause  immediate  death  weeks  after  the  primary  infection. 
Similar  disorganization  occurs  in  the  peripheral  nerves,  leading  to  the 
famihar  diphtheric  paralysis,  which  usually  begins  with  paralysis  of 
the  soft  palate  and  marked  by  the  mufSed  voice  of  the  patient. 
Deglutition  may  be  so  interfered  with  as  to  lead  to  a  regurgitation 
into  the  nose  during  the  act  of  swallowing,  but  this  peripheral  nerve 
paralysis  may  be  very  widespread,  so  that  the  patient  is  unable  to 
walk,  or  in  other  cases  the  trunk  muscles  are  involved,  which,  in  a 
few  instances,  causes  the  muscles  of  respiration  to  become  weak  or 
actually  paralyzed.  Frequently  in  diphtheria  the  knee-jerk  is  early 
abolished. 

A  practically  important  question  is.  How  soon  after  his  illness 
should  a  patient  be  permitted  to  go  about?    It  may  be  safely  said  that 


I04  CLINICAL  MEDICINE 

this  he  cannot  do  so  long  as  he  has  a  discharge  from  the  nose,  for  that 
may  remain  highly  infective  long  after  his  throat  or  other  symptoms 
have  subsided;  similarly,  any  other  discharge,  such  as  from  the  ears,  is 
dangerous.  Fortunately,  unlike  the  case  of  the  t3qDhoid  bacillus,  the 
urine  is  not  infected  after  diphtheria. 

In  the  kidneys  mischiefs  caused  by  the  diphtheria  toxin  are  quite 
varied.  Sometimes  it  may  take  the  form  of  a  glomerular  nephritis. 
At  other  times  the  epithelium  lining  of  the  tubules  may  be  the  most 
changed,  but  the  commonest  derangement  is  in  the  form  of  an 
interstitial  nephritis,  which  is  very  destructive;  though  a  permanent 
interstitial  alteration  is  not  as  frequent  a  sequel  as  after  scarlatinal 
nephritis.  In  some  instances,  however,  the  infection  of  the  kidneys 
is  the  immediate  cause  of  death.  When  the  diphtheria  bacillus 
itself  enters  the  blood  in  the  manner  which  we  have  described  it  may 
cause  endocarditis,  as  already  intimated.  Other  extensions  of  the 
diphtheria  process,  such  as  diphtheria  of  the  stomach,  do  occur,  but 
are  uncommon. 

Laryngeal  diphtheria  is  characterized  by  a  different  development 
of  the  membrane,  due  to  the  change  from  the  throat  to  the  tissues  of 
the  larynx  and  trachea.  The  membrane,  not  having  in  this  situation 
the  same  depth  of  submucous  tissue,  is  often  much  looser  in  its  attach- 
ments, and  hence  is  not  infrequently  found  as  a  detached  cast  within  the 
lumen  of  the  tube,  and  may,  indeed,  be  coughed  up  as  such  by  the  pa- 
tient. On  the  other  hand,  its  extension  into  the  bronchi  and  smaller 
bronchioles  may  be  one  of  the  chief  causes  of  death,  due  largely  to  suf- 
focation, induced  by  the  struggles  of  the  patient  for  breath,  as  well  as 
the  coughing.  Virulent  particles  are  thus  inhaled,  and  set  up  exten- 
sive bronchopneumonia,  a  common  cause  of  the  fatality  in  diphtheria. 
In  such  cases,  when  the  difficulty  of  breathing  becomes  marked,  the 
question  of  advisabihty  of  tracheotomy  or  of  O'Dwyer's  intubation 
becomes  imperative.  The  general  trend  of  opinion  is  now  more  in 
favor  of  the  intubation  method,  on  account  of  the  many  dangers  which 
accompany  the  tracheotomy,  along  with  the  use  of  the  double  tra- 
cheotomy tube,  which  is  apt  to  become  clogged  up  by  the  membranes 
being  coughed  into  it.  A  sudden  attack  of  vomiting  during  conva- 
lescence is  always  an  alarming  symptom,  as  it  is  a  sign  of  degeneration 
of  the  vagus  nerve. 

One  of  the  worst  local  developments  occurs  in  the  conjunctiva, 
which  can  become  variously  infected,  but  chiefly  by  the  fingers  of  the 
patient.  The  treatment  of  this  complication  cannot  be  too  prornpt, 
for  the  tissues  of  this  delicate  organ  become  so  rapidly  involved  that  a 


DIPHTHERIA  IO5 

loss  of  one  or  both  eyes  follows,  particularly  if  diphtheria  occurs  dur- 
ing an  attack  of  measles,  as  it  not  uncommonly  does.  Since  measles 
specifically  affect  the  conjunctiva,  the  conjunctivitis  caused  by  the 
diphtheric  exudation  there  becomes  so  severe  that  it  is  doubtful  if 
the  eye  can  then  be  saved. 

Dimness  of  vision  occasionally  occurs  as  the  result  of  the  diphtheria 
toxin,  and  may  be  due  to  the  weakness  of  the  ciliary  muscle,  or  to 
impKcation  of  the  retina  itself,  with  contraction  of  the  field  of  vision. 
Squint  resulting  from  paralysis  of  one  or  more  of  the  ocular  muscles 
occasionally  happens,  as  well  as  temporary  ptosis.  The  pupil  is  un- 
affected, though  it  may  remain  dilated  and  sluggish. 

The  early  diagnosis  of  diphtheria  is  of  great  importance,  and  we 
may  say  that  it  cannot  be  estabKshed  by  the  character  of  the  exuda- 
tion, but  only  by  a  bacteriologic  examination.  A  membranous  exu- 
date can  extend  from  the  tonsils  to  the  pharynx  and  soft  palate,  in- 
cluding the  uvula,  closely  resembling  diphtheric  exudation,  and  yet 
may  be  wholly  caused  by  a  streptococcus.  Follicular  tonsillitis  is 
also  very  common,  marked  by  an  exudation  in  the  deep  follicles  of  the 
tonsils,  and  quite  often  accompanied  by  a  general  constitutional  dis- 
turbance and  prostration,  and  yet  not  be  diphtheric.  At  the  same 
time,  as  we  have  remarked,  a  true  and  very  dangerous  though  limited 
development  of  a  diphtheric  membrane  may  be  found  on  the  tonsils, 
of  which  only  a  bacteriologic  examination  can  determine  its  character. 
Nasal  diphtheria  also  may  be  accompanied  with  so  little  discharge 
as  to  be  easily  overlooked.  A  widespread  paralysis  of  the  peripheral 
nerves  has  often  come  to  my  notice,  in  which  the  patients  could  not 
remember  that  they  had  had  a  sore  throat. 

The  diagnosis  can  never,  therefore,  be  regarded  as  certain  unless 
established  by  a  bacteriologic  examination.  In  laryngeal  diphtheria 
a  valuable  diagnostic  symptom  is  the  rigidity  of  the  sternocleidomas- 
toid muscles. 

Treatment. — We  have  already  shown  that  the  chief  advance  in 
the  treatment  of  diphtheria  has  been  by  the  employment  of  the 
diphtheria  antitoxin.  In  other  respects  particular  measures  against 
local  lesions  may  be  adopted:  first  in  importance  is  the  prompt  and 
thorough  douching  of  the  affected  part,  as  already  described,  but 
in  other  respects  the  physician  ought  to  know  how  to  deal  with  cer- 
tain complications.  The  results  of  the  diphtheric  membrane  on  the 
conjunctiva  we  have  already  cited.  The  treatment  for  this  compH- 
cation  should  consist  of  repeated  injections  under  the  eyelids  of  a  boric 
acid  solution  in  distilled  water,  while  the  edges  of  the  eyelids  should 


Io6  CLINICAL  MEDICINE 

be  smeared,  from  within  outward,  with  the  ointment  of  ammoniated 
mercury.  The  swelling  of  the  eyeHds  requires  that  these  procedures 
should  be  as  gentle  as  possible,  though  the  eye  may  be  continuously 
douched  with  warm  water  which  has  been  previously  boiled,  the 
patient  lying  on  his  side,  so  as  to  let  the  fluid  run  out  readily  from  the 
outer  angle  of  the  eyehd.  Due  to  the  rapidity  of  the  morbid  process 
these  measures  should  be  continued  as  uninterruptedly  as  possible — ■ 
douched  from  the  douche-bag  but  slightly  elevated  from  the  head. 

Treatment  of  Peripheral  Paralysis. — In  peripheral  paralysis  of  the 
soft  palate  an  appHcation  should  be  immediately  made  to  the  parts 
of  red  pepper  mixed  with  honey,  apphed  with  a  soft  camel's-hair  brush, 
as  red  pepper  does  not  produce  any  local  inflammation,  but  only 
local  hyperemia,  and,  unHke  the  tongue,  the  palate  and  pharynx  are 
insensitive  to  red  pepper.  This  application  may  be  very  freely  made 
twice  a  day.  For  peripheral  paralysis  of  the  extremities  or  trunk  there 
is  no  measure  so  effective  as  wrapping  the  parts  up  in  cloths  wet  with 
an  infusion  of  red  pepper,  of  the  strength  of  i  dram  of  red  pepper  to 
the  pint  of  boiling  water.  The  duration  of  the  paralysis  may  by  this 
measure  be  very  materially  cut  short,  and  is  much  superior  to  elec- 
tricity. All  local  antiseptic  applications  are  of  doubtful  value,  and 
may  be  injurious  to  the  throat  if  they  are  at  all  irritating. 

Previous  to  the  introduction  of  antitoxin  I  reHed  exclusively  on 
the  use  of  bromin  locally  and  as  a  medicine  administered  internally. 
My  reason  was,  there  is  no  such  efficient  germicide  as  bromin. 
The  only  preparation  of  bromin  that  can  be  used  for  such  purpose  is 
Lawrence  Smith's  solution  of  bromin  with  bromid  of  potassium.  This 
solution  can  be  put  up  diluted  with  water,  a  dram  of  it  to  the  ounce  of 
water,  and  then  applied  locally.  In  bad  cases  I  have  even  applied  the 
solution  clear.  Internally  I  give  it  in  doses  of  |  to  i  dram  in  i  oz.  of 
sweetened  water  or  milk.  Bromin  is  not  only  a  powerful  germicide, 
but  also  in  this  solution  can  be  applied  without  producing  any  irrita- 
tion, when,  moreover,  it  acts  as  the  best  deodorizer.  I  have  no  doubt 
that  in  many  cases  of  incipent  diphtheria  this  application  was  of 
great  use,  but  of  Httle  avail  when  the  membrane  was  very  extensive. 

In  diphtheric  affections  of  the  heart  I  would  strongly  protest  against 
the  use  of  digitalis,  for  I  have  seen  the  most  distressing  effects  fol- 
low^  its  administration.  This  ought  to  be  expected,  since  we  know 
that  digitalis  has  no  power  for  increasing  the  force  of  the  heart-beat 
in  any  cases  of  toxic  weakening  of  the  heart  muscles.  Thus  it  alto- 
gether fails  for  this  purpose,  both  in  the  cardiac  debility  of  pneumonia 
and  of  typhoid  fever.     Its  routine  administration  is  based  upon  a 


PERTUSSIS  — WHOOPING-COUGH  I07 

mistaken  idea  that  digitalis  stimulates  the  contractility  of  the  heart. 
It  is,  therefore,  of  great  use  when  the  heart  is  dilated  in  valvular  and 
not  in  febrile  affections,  because  it  produces  a  cramp-like  contraction 
of  the  dilated  ventricles.  Meantime  it  contracts  the  arteries,  and  as  in 
diphtheria  the  arteries  are  everywhere  contracted,  digitahs  further 
embarrasses  the  weakened  heart  by  the  difficulty  which  it  induces  in 
the  circulation,  owing  to  the  diminished  lumen  of  the  blood-vessels. 
Strychnin  is  of  some  (but  limited)  use  in  diphtheric  weakening  of  the 
heart,  but  the  most  potent  remedy  is  the  hypodermic  administration 
of  I  gram  or  7I  gr.  of  camphor,  dissolved  in  20  min.  of  sterilized  olive 
or  almond  oil. 

When  possible  the  patient  should  be  isolated  in  a  large  airy  room, 
stripped  of  all  carpets  and  hangings,  so  that  it  may  be  more  easily 
disinfected  afterward.  The  diet  should  be  exclusively  milk  and  lime- 
water.  In  laryngeal  cases  ice-cream  is  of  use  also,  and  there  is  no 
disease  in  which  alcohol  can  be  so  freely  employed  to  counteract  pros- 
tration. 

Affections  of  the  kidneys  in  diphtheria  may  be  very  serious,  first  caus- 
ing hemorrhage  and  then  suppression.  This  disorder  has  no  resem- 
blance to  the  nephritis  caused  by  scarlatina,  and  its  treatment  should 
be  by  hypodermoclysis,  which  can  be  best  done  in  either  flank  and 
should  amount  to  fully  8  oz.  of  normal  saline.  Meantime  this  should 
be  supplemented  by  rectal  irrigation  with  Kemp's  rectal  irrigator, 
using  at  least  2  gallons  of  normal  saline  twice  a  day. 

PERTUSSIS— WHOOPING-COUGH 

Pertussis  is  essentially  a  spasmodic  nervous  disease  affecting 
the  larynx  and  caused  by  an  infection  whose  specific  agent  has  not 
yet  been  identified.  Statistics  show  that  on  account  of  its  compli- 
cations pertussis  causes  more  deaths  than  do  scarlet  fever  or  diph- 
theria. 

Although  highly  infectious,  yet  not  everyone  can  contract  it, 
however  long  he  be  exposed  to  it.  Of  my  father's  four  children,  not 
one  was  infected  by  it,  though  each  slept  in  the  same  room  or  bed  with 
those  who  had  it,  and  in  my  boyhood  I  shared  the  same  bed  with  one 
who  had  it  severely  for  three  months.  In  my  own  case  I  seem  to  be 
immune  against  almost  everything,  having  only  caught  measles  in 
early  Kfe.  While  as  physician  to  the  New  York  Quarantine  I  was 
exposed  to  every  communicable  disease,  from  the  deadly  typhus,  which 
is  now  nearly  extinct,  to  Asiatic  cholera.  Unfortunately,  I  could  not 
transmit  this  immunity,  for  my  seven  children  were  prone  to  catch 


Io8  CLINICAL   MEDICINE 

everything,  three  of  them  succumbing  to  their  infections.  Small 
wonder,  therefore,  that  the  important  subject  of  immunity  is  one  of 
the  most  recondite  and  baffling  of  medical  problems. 

The  disease  is  more  than  twice  as  fatal  in  the  negro  race  than  in 
others.  The  incubation  period  of  this  infection  varies  from  seven  to 
ten  days. 

Symptoms. — In  the  majority  of  cases  it  begins  as  a  simple  cold  in 
the  head,  with  slight  fever,  running  at  the  nose,  watery  eyes,  and  an 
incessant  cough,  at  first  without  expectoration.  But  the  cough  lasts 
unaffected  by  the  usual  remedies,  and  after  a  week  takes  on  a  convul- 
sive character,  with  no  attempt  to  interrupt  the  expiratory  cough 
with  any  act  of  inspiration,  as  in  other  prolonged  coughs.  Now  fol- 
lows a  series  of  some  twenty  short  coughs,  during  which  the  child 
becomes  blue  in  the  face,  when  at  last  a  deep  inspiration  is  taken,  which 
on  account  of  laryngeal  spasm  causes  the  "whoop"  from  which  the 
disease  takes  its  name.  Like  other  spasmodic  nervous  diseases,  an 
aura  very  commonly  precedes  the  attack,  so  that  the  child,  by  this, 
knows  that  it  is  coming  on,  and  runs  to  its  nurse  or  even  clutches  at 
any  support  in  its  neighborhood.  The  attack  often  ends  in  vomiting, 
and  in  cases  of  very  frequent  attacks  the  food  may  be  so  often  rejected 
as  seriously  to  affect  the  nutrition.  Owing  to  the  extensive  venous 
congestion,  subcutaneous  hemorrhages  occur,  particularly  about  the 
forehead,  with  ecchymoses  of  the  conjunctiva  and  epistaxis. 

Enlargement  of  the  bronchial  glands  is  quite  common,  and  may 
be  one  of  the  causes  of  the  laryngeal  spasm. 

The  chief  dangers  of  whooping-cough  are  from  general  bronchitis, 
causing  bronchopneumonia.  This  is  just  what  we  might  expect  from 
the  sudden  spasmodic  narrowing  of  the  glottis,  for  a  local  constriction 
happening  anywhere  in  the  course  of  a  bronchus,  or  by  external  press- 
ure, produces  serious  results,  and  even  more  so  when  the  narrowing 
occurs  at  the  very  beginning  of  the  respiratory  tract. 

Treatment. — By  far  the  chief  indication  in  the  treatment  of  whoop- 
ing-cough is  to  prevent  and  aboUsh  the  laryngeal  spasms.  I  can  speak 
strongly  on  this  subject,  because  we  have  a  specific  remedy  for  this 
which  will  stop  the  whoop  in  a  very  few  days,  and  that  is  belladonna, 
properly  administered.  All  depends  on  the  mode  of  its  administration, 
and  the  sooner  this  is  properly  done,  the  better.  Differing  from  opium, 
which  children  bear  badly,  the  tolerance  of  children  for  belladonna 
is  remarkable,  as  was  conclusively  shown  by  Fuller.  My  rule  is  to 
begin  with  3  drops  of  the  tincture,  for  the  first  dose,  and  increase  by 
I  drop  for  the  subsequent  doses,  at  intervals  of  three  hours,  until  the 


PERTUSSIS — WHOOPING-COUGH  109 

dose  is  reached  which  produces  general  reddening  of  the  skin,  beyond 
which  further  increase  is  not  necessary.  The  dose  which  causes  this 
reddening  may  then  be  steadily  continued  every  three  hours  until 
the  whoop  ceases  or  occurs  only  at  long  intervals,  when  the  bella- 
donna may  be  given  at  longer  intervals,  the  original  dosing  being  at 
once  resumed  if  the  attacks  become  more  frequent.  In  the  majority 
of  cases  the  whoop  ceases  under  this  treatment  within  four  days.  It 
must  not  be  supposed,  however,  that  the  disease  ceases  ^\'ith  the  whoop, 
for  I  have  had  children  who  have  not  whooped  at  all  for  four  weeks, 
then  catch  cold  and  have  the  whoop  return  as  bad  as  ever,  with  the 
further  disadvantage  that  this  relapse  is  more  difficult  to  cure  than 
the  original  attack. 

Occasionally  a  complication  occurs  in  the  course  of  the  disease — 
accumulation  of  flatus  in  the  bowels,  with  now  and  then  diarrhea. 
This  is  best  treated  by  10  gr.  of  subcarbonate  of  bismuth  with  i  gr. 
of  betanaphthol  every  three  hours. 

After  the  whoop  has  been  suppressed  by  the  belladonna,  it  is  still 
necessary  to  prevent  the  ^hild  from  catching  cold,  as  above  noted. 
For  this  purpose  I  strongly  recommend  the  same  measure  spoken  of 
in  the  treatment  of  bronchitis  in  children,  namely,  that  the  child 
should  sleep  in  a  bag  of  canton  flannel,  the  upper  end  tied  securely 
about  the  neck.  In  an  extensive  family  practice  in  former  years  I 
never  found  this  treatment  to  fail,  and,  moreover,  I  have  never  lost  a 
case  of  whooping-cough. 

The  most  sensitive  part  of  the  body  to  surface  chill  is  the  skin  of 
the  forearms.  Among  the  host  of  remedies  recommended  for  whoop- 
ing-cough, I  have  no  faith  in  any  of  them,  except  perhaps  heroin,  which 
may  be  given  in  yV  E^-  tablets  at  night.  In  weakly  children,  who  begin 
the  disease  with  their  condition  already  debilitated,  a  dessertspoonful 
of  cod-liver  oil  should  be  administered  three  times  a  day,  after  eating. 

Whooping-cough  not  uncommonly  predisposes  to  tubercular  in- 
fections, or  it  may  be  the  beginning  of  a  lifelong  asthma,  the  treatment 
of  which  is  described  on  page  309.  One  fact  cannot  be  too  strongly 
emphasized,  and  that  is  the  danger  of  every  case  of  whooping-cough 
infecting  others  susceptible  to  the  disease.  This  infection  undoubtedly 
may  occur  during  the  catarrhal  stage  of  the  disease,  but  there  is  no 
telling  when  the  infection  ceases  to  be  communicable ;  therefore  every 
case  of  whooping-cough  should  be  jealously  kept  from  other  children 
for  at  least  three  months  from  the  onset  of  the  complaint. 


no  CLINICAL  MEDICINE 

MUMPS— EPIDEMIC  PAROTITIS 

This  is  a  very  common  disease  due  to  an  infection  whose  specific 
agent  has  not  been  identified.  That  it  is  highly  contagious  is  shown 
by  its  rapid  spread  among  young  recruits  in  barracks,  in  schools,  and 
similar  institutions,  especially  when  crowded.  It  has  no  characteristic 
premonitory  symptoms,  but  begins  with  moderate  fever  and  usually  a 
swelling  of  the  parotid  glands  on  one  side.  This  swelKng  becomes 
rapidly  very  pronounced,  causing  a  bulging  not  only  of  the  cheek,  but 
also  of  the  lower  structures  about  the  external  ear.  After  the  third 
day  the  parotid  on  the  other  side  becomes  involved  also,  with  a  very 
characteristic  tumefaction  of  the  sides  of  the  face  and  neck.  In  a 
majority  of  cases  this  condition,  even  when  there  is  a  good  deal  of 
swelling,  is  not  accompanied  by  marked  systemic  symptoms,  but 
occasionally  there  is  high  fever,  a  good  deal  of  pain  on  swallowing,  and 
even  dehrium.  It  is  difficult  also  for  the  child  to  open  its  mouth  and 
to  swallow.  The  disease  is  by  no  means  fatal,  and  lasts,  as  a  rule,  for 
a  full  week. 

Mumps,  however,  is  characterized  by  one  singular  complication, 
namely,  orchitis.  Although  there  is  a  great  deal  of  swelhng  and  pain 
about  the  infected  organ,  yet  suppuration  is  not  a  feature  of  the  dis- 
ease. Unfortunately,  however,  cases  do  occur  in  which  the  orchitis 
is  followed  by  atrophy  of  one  or  both  glands.  I  have  myself  had  an 
instance  in  a  married  man  in  which  only  traces  of  the  testicles  were  to 
be  found.  He  nevertheless  had  preserved  sexual  power,  but,  to  the 
great  disappointment  to  himself  and  his  wife,  he  had  had  no  children. 
In  a  few  cases  at  the  height  of  the  disease  otitis  media  occurs,  which 
may  be  followed  by  more  or  less  deafness. 

Treatment. — In  the  majority  of  instances  no  treatment  other  than 
being  confined  to  bed  is  necessary.  When  the  swelling  is  great,  much 
rehef  may  be  obtained  by  wrapping  the  neck  and  cheeks  in  cotton 
batting  upon  which  laudanum  has  been  sprinkled,  and  then  covering 
with  oiled  silk. 

When  otitis  is  complained  of,  the  laudanum  may  be  dropped  into 
the  ear  by  the  apparatus  ordinarily  used  for  filHng  fountain  pens,  and 
then  a  pledget  of  cotton  may  be  left  in  place,  care  being  taken  not  to 
push  it  in  too  deeply.  Only  Hquid  nourishment  can  be  administered 
at  this  time. 

For  the  orchitis,  the  testicles  should  be  supported  by  the  ordinary 
suspensory  bandage  used  for  such  purposes  in  other  conditions,  and 
the  patient  confined  to  his  bed  until  all  symptoms  have  subsided. 


INFLUENZA— LA    GRIPPE  III 

INFLUENZA— LA  GRIPPE 

This  remarkable  infection  has  prevailed  from  ancient  times,  the 
most  probable  proof  of  which  is  from  allusions  to  widespread  epidemics 
which  came  and  disappeared  in  former  times,  but  without  the  clinical 
features  of  the  other  infectious  diseases  which  we  have  been  reviewing. 
The  most  sahent  feature  about  influenza  is  its  sudden  development 
as  a  special  pandemic,  but  it  was  not  until  late  years  that  its  various 
accompaniments  have  been  identified  with  the  disease.  As  no  other 
disease  is  characterized  by  such  rapid  onset  in  a  community,  it  was 
natural  that  for  a  long  time  it  should  be  regarded  as  depending  on 
meteorologic  conditions,  but  it  is  now  pretty  definitely  settled  that 
it  follows  the  tracks  of  commerce  so  surely  that  we  must  regard 
it  as  always  proceeding  from  person  to  person  rather  than  from  place 
to  place. 

Its  clinical  features  and  accompaniments  differ  remarkably  accord- 
ing to  its  particular  epidemic  prevalence,  many  of  its  striking  pecu- 
liarities occurring  chiefly  when  it  first  invades  a  community.  On  that 
account  I  prefer  to  mention  my  own  personal  experience  with  the 
epidemic  in  New  York  in  the  year  1890.  I  was  attacked,  while  riding 
in  my  carriage,  with  a  sudden  acute  pain  in  my  forehead.  I  drove 
home  and  at  once  went  to  bed  for  the  first  time  in  twenty  years  from  ill- 
ness. The  pains  rapidly  developed  in  my  Hmbs,  with  the  ordinary  char- 
acteristics of  an  acute  febrile  infection.  The  catarrhal  symptoms  were 
but  moderate,  though  when  these  subsided  I  had  a  sense  of  general  pros- 
tration which  lasted  for  six  weeks.  In  that  epidemic  muscular  debihty 
was  everywhere  complained  of.  My  experience  among  some  patients 
during  the  subsequent  months  of  its  prevalence  was  unlike  that  of  any 
cases  which  I  have  seen  since,  and  the  first  that  I  would  refer  to  were 
infections  of  the  nervous  system.  I  knew  of  10  cases  of  sudden  devel- 
opment of  insanity,  including  2  suicides,  and  2  cases  of  chronic  insanity 
which  followed  some  very  characteristic  symptoms  of  influenza.  Dur- 
ing the  epidemic  of  that  year  I  met  a  number  of  cases  of  intractable 
vomiting,  3  of  whom  were  fatal,  the  vomited  masses  being  greenish, 
and  with  a  sour  odor  which  filled  the  room.  In  each  of  these  cases 
the  patients  died  during  an  attack  of  syncope.  In  i  case  the  patient 
recovered  from  vomiting,  but  soon  afterward  the  skin  desquamated 
from  head  to  foot.  Besides  this,  I  saw  some  other  curious  cases  in 
consultation,  a  principal  symptom  of  which  was  profuse  sweating. 
One  was  in  a  patient  of  the  late  Dr.  Erskine  Mason,  in  which  the  per- 
spiration ran  through  the  mattress  and  dropped  upon  the  floor. 

As  a  rule,  the  first  signs  are  those  of  a  catarrh  of  the  respiratory 


112  CLINICAL  MEDICINE 

tract,  beginning  in  the  nose,  and  then  traveling  down  with  signs  of 
bronchitis,  and  lastly,  with  development  of  scattered  areas  of  bron- 
chopneumonia. Throughout,  the  fever  does  not  run  high.  The  cough 
may  be  either  sHght  or  very  severe,  with  viscid  expectoration,  in  which 
yellowish  globules  are  suspended,  and  which,  on  examining  with  a 
high-power  microscope,  may  first  reveal  the  true  nature  of  the  infec- 
tion. This  cough  with  its  bronchitis  may  soon  subside,  but  in  some 
cases  continues  for  two  months  or  more.  Occasionally  the  process 
extends  to  the  pleura,  producing  the  localized  pleuritis  or  even  em- 
pyema, the  bacillus  being  found  in  pure  culture  in  the  purulent  collec- 
tions. Besides  symptoms  referred  to  the  respiratory  organs,  we  may 
have  widely  scattered  disorders,  chiefly  of  a  nervous  kind.  Severe 
attacks  of  pain  may  be  localized  either  in  the  head,  in  the  sides  of  the 
chest,  or  in  the  abdomen.  At  other  times  one  or  both  the  sciatic 
nerves  may  be  involved,  but  through  them  all  there  is  the  significant 
accompaniment  of  general  muscular  debility.  For  these  pains,  often 
markedly  periodic,  we  have  a  specific  in  the  form  of  fluidextract  of 
ergot,  to  be  given  in  dram  doses,  which  may  be  repeated  in  three  hours, 
but  often  the  first  dose  is  sufficient. 

The  causative  agent  of  this  disease  was  first  demonstrated  by 
Pfeiffer  in  1892  and  1893,  and  consists  of  a  minute  bacillus  which  can 
be  recovered  in  pure  culture  from  the  pellets  above  mentioned,  sus- 
pended in  the  expectoration.  A  remarkable  peculiarity  of  this 
organism  is  that  it  may  be  found  stored  up  in  locaHties  either  in  the 
respiratory  tract  or  in  out-of-the-way  places  throughout  the  body. 
Thus,  it  has  been  found  in  the  gall-bladder,  in  abscesses  in  the  limbs, 
and  also  in  the  substance  of  boils.  It  has  been  demonstrated  as 
thus  continuing  for  one  or  two  years  after  its  systemic  symptoms  have 
all  disappeared,  quite  similar  in  this  respect  to  the  long  survival  in 
some  situations  of  the  typhoid  bacillus  after  the  patient  has  wholly 
recovered  from  the  primary  infection.  It  is  this  peculiarity  which  has 
caused  some  writers  to  advance  the  explanation  of  the  outbreak  of 
influenza  in  scattered  localities,  both  in  Europe  and  America,  so  as 
to  connect  various  epidemics  in  different  years  with  one  another. 

Though  the  mortality  from  influenza  itself  is  not  very  high,  yet 
every  epidemic  is  accompanied  by  a  greatly  increased  death-rate  in 
the  locality,  and  notably  by  the  subsequent  development  or  progress 
of  phthisis.  This  is  just  what  we  should  expect  from  an  infection 
causing  chronic  bronchopneumonia,  and  for  similar  reasons  the  pul- 
monary lesions  show  a  very  marked  mixed  infection  with  pneumo- 
cocci,  various  streptococci,  and  the  influenza  baciUus  in  conjunction 


SYPHILIS 


"3 


with  the  tubercle  bacillus.  On  the  other  hand,  a  very  chronic  cough 
with  localized  areas  of  induration  may  be  caused  by  the  influenza 
bacillus,  so  that  from  the  cUnical  symptoms  alone,  which  may  include 
hemoptysis,  it  would  be  impossible  to  estabHsh  the  diagnosis.  But 
if  there  is  a  considerable  amount  of  expectoration  and  of  persistent 
absence  in  it  of  the  tubercle  bacilli,  the  presence  of  the  influenza  bacil- 
lus should  be  looked  for. 

Treatment. — Our  remarks  on  treatment  wiU  be  brief,  because  I 
think  that  I  have  found  a  true  specific  against  this  infection,  and  it 
consists  of  the  following  prescription:  Phenacetin,  3  gr.;  sulphate  of 
quinin,  2  gr.;  Dover's  powder,  |  gr.;  extract  of  aconite  i  gr.,  made 
into  I  pill,  6  of  these  pills  to  be  taken  through  the  first  day.  On  the 
second  and  third  days  i  pill  before  each  meal,  and  2  at  night  should 
be  administered.  In  the  majority  of  cases  the  disease  subsides  on  the 
third  day  of  this  medication,  but  in  cases  of  very  chronic  cough  there 
may  be  continued  i  pill,  four  times  a  day,  for  several  weeks.  The 
most  striking  change  in  the  symptoms,  whether  constitutional  or 
local,  is  shown  on  the  second  day.  These  pills  are  now  sold  by  the 
thousand  in  different  parts  of  the  country  under  the  name  of  the 
compound  phenacetin  pill  (Thomson),  the  formula  in  each  case  being 
given  on  the  label.  I  am  assured  that  this  combination  is  quite  as 
specific  against  the  influenza  bacillus  as  quinin  in  ague  and  mercury 
in  syphilis. 

Chronic  Diseases  Immediately  Communicable  or  Contagious 

syphilis 

No  disease  merits  the  designation  "contagious"  more  than  s>^hilis. 
It  is  originally  propagated  only  by  actual  contact.  Notwithstanding 
its  multiform  and  remarkably  varied  manifestations,  it  remains  through- 
out them  all  the  same  specific  affection,  due,  as  now  demonstrated,  to 
an  infection  by  a  single  organism.  The  unity  of  syphilis,  therefore, 
can  no  longer  be  denied. 

Like  other  general  infections,  its  historic  origin  is  obscure.  Thus, 
it  has  been  asserted  that  it  was  described  by  a  Chinese  writer  2637  years 
before  Christ,  but  with  no  better  grounds  for  beHef  than  its  supposed 
identification  with  the  most  diverse  lesions  mentioned  in  the  writings 
of  antiquity.  It  is  incredible  that  syphiHs,  as  known  to  us,  should 
not  have  been  observed  by  the  Greek  and  Roman  physicians,  because 
they  were  both  careful  and  clear  in  their  descriptions  of  the  symptoms 
of  diseases,  and,  moreover,  opportunities  for  propagating  it  then  were 


114  CLINICAL  MEDICINE 

beyond  those  even  of  modern  times,  as  impure  sexual  intercourse  was 
sometimes  actually  sanctioned  by  their  rehgion.  Their  hterature, 
particularly  that  of  their  satirists,  allowed  their  repeatedly  alluding  to 
the  ravages  of  syphilis,  if  they  were  at  all  acquainted  with  them. 
Juvenal  would  have  taken  advantage  of  parading  the  hideous  mani- 
festations of  syphilis  on  the  countenance  more  than  Shakespeare  does. 
It  is  admitted  by  all  authorities  that  this  disease,  as  we  now  know  it, 
dates  from  about  the  close  of  the  fifteenth  century.  Its  manifestations 
at  that  time  were  extraordinarily  serious,  as  is  commonly  the  case 
with  entirely  new  epidemics.  These  severe  developments  gradually 
decreased  until  the  disease  has  assumed  its  present  character. 

S5^hiHs  has  been  classed  by  eminent  writers  among  the  exanthe- 
mata, like  scarlet  fever  and  small-pox,  but  syphihs  radically  differs 
from  such  acute  affections  by  being  the  most  chronic  of  diseases,  often 
lasting  for  a  Hfetime  in  the  development  of  its  later,  but  always 
specific,  lesions.  Neither  small-pox  nor  any  other  exanthem  continues 
to  manifest  its  presence  by  special  symptoms  not  for  one  but  for 
twenty  years  after  the  first  infection.  Some  of  the  late  sequelae  of 
these  exanthemata  are  really  due  to  subsequent  infections  by  very 
different  organisms. 

That  syphilis  should  be  classed  as  an  exanthem  would  be  natural 
if  the  characters  of  its  secondary  stage  were  alone  observed.  After 
the  first  infection  there  follows  a  definite  period  of  incubation,  at  the 
end  of  which,  as  in  the  exanthemata,  a  fever  occurs,  with  a  general 
eruption  on  the  cutaneous  and  mucous  surfaces.  But,  unlike  exan- 
themata, the  symptoms  of  the  second  stage  are  followed  by  a  series  of 
characteristic  disorders  which  may  develop  in  every  tissue  of  the 
body.  These  may  continue  indefinitely  through  long  years.  Also, 
unhke  exanthemata,  it  can  be  propagated  to  the  unborn  offspring  of 
syphilitic  parents,  and  that  it  is  the  same  disease  is  proved  by  the 
presence  of  its  own  special  organism  in  the  infected  offspring.  It  is 
true  that  small-pox  may  be  so  propagated  through  the  blood  of  the 
mother,  but  like  small-pox  elsewhere  it  quickly  passes  through  special 
phases  and  ceases,  but  congenital  syphihs  continues  as  a  permanent 
infection,  so  that  it  is  truly  inherited  syphihs  and  not  an  inherited  ex- 
anthem. 

The  contagiousness  of  S3rphihs  is  strikingly  illustrated  by  its 
transmission  from  one  person  to  another  by  mere  contact  with  its 
secretions;  thus,  the  secretions  of  the  mouth  of  a  syphihtic  infant 
may  convey  the  disease  to  a  healthy  wet  nurse.  Physicians  are  also 
repeatedly  infected  through  some  abrasion  on  their  fingers  while  at- 


SYPHILIS  115 

tending  syphilitic  women  in  confinement.  Hence,  it  is  incorrect  to 
class  this  infection  with  other  diseases  whose  clinical  course  is  totally 
diiTerent,  simply  because,  at  one  period,  it  resembles  an  exanthem. 

The  truth  is,  as  we  shall  see,  that  syphiHs  resembles  nearly  every- 
thing in  its  manifestations  without  being  the  actual  thing.  For  ex- 
ample, it  is  one  means  of  diagnosing  a  syphiHtic  eruption,  that  though 
it  may  closely  simulate  other  cutaneous  affections,  it  always  remains 
different  from  them  in  some  important  particulars.  Unhke  the  exan- 
themata, which  usually  are  simply  infections  of  the  blood,  s>phiHs 
ultimately  involves  every  texture  and  tissue  of  the  body.  Usually 
beginning  in  a  moral  dehnquency,  it  then  becomes  the  most  universal 
physical  curse  which  is  known,  and  not  the  least  serious  is  its  hereditary- 
transmission  to  which  we  have  alluded,  though  by  proper  treatment 
its  first  stages  may  be  cured  in  the  children  who  have  survived.  Yet 
years  afterward  it  shows  its  continuous  operation  in  them  by  the 
notched  appearance  of  the  permanent  teeth  (incisors). 

Etiology. — Though  long  suspected  to  be  due  to  an  infection  by  a 
specific  organism,  which  was  erroneously  identified  with  different 
agents  by  various  investigators,  it  was  not  until  1905  that  it  was 
demonstrated  by  Schaudinn  to  be  owing  to  a  spirilla  presenting  dis- 
tinct characters,  and  which  he  named  Spirochaeta  pallida.  This  is 
a  long,  delicate,  non-refractile,  spirally  curved  organism,  whose  aver- 
age length  is  from  4  to  14  mm.  Some  of  them,  however,  are  only  from 
2  to  3  mm.  in  length,  while  others  20  mm.  long  have  been  observed. 
It  is  pointed  at  both  ends,  with  sharp,  clear-cut,  corkscrew-like 
spirals;  the  large  number  of  spirals  in  proportion  to  the  length  of 
the  organism  being  a  characteristic  feature.  Extremely  dehcate  fla- 
gellae  are  present,  usually  one  at  each  end.  It  is,  therefore,  a  motile 
organism,  moving  actively  in  the  blood  and  through  the  tissues.  It 
has  no  spores.  One  of  its  most  marked  characteristics  is  that  it  stains 
with  difficulty.  It  does  not  stain  by  Gram's  method.  It  is  found  in 
the  greatest  numbers  in  sections  of  organs  from  children  dead  of  con- 
genital syphiHs,  in  which  cases  the  tissues  may  literally  swarm  with 
the  organism.  Among  the  spirilla  it  most  resembles  the  Spirochaeta 
refringens,  but  the  latter  is  larger,  thicker,  and  quite  easily  stained, 
while  its  spirals  are  broad  and  wavy  rather  than  corkscrew  shaped. 

That  it  is  the  specific  cause  of  syphilis  is  proved  by  its  constant 
appearance  in  primary  and  secondary  syphilitic  lesions,  appearing 
unmixed  with  other  organisms  in  the  depth  of  such  lesions  and  in  the 
blood.  It  is  in  the  most  contagious  syphilitic  lesions  (chancre,  con- 
dyloma, and  mucous  patch)  that  this  organism  is  most  often  found. 


Il6  CLINICAL  MEDICINE 

It  is  also  found  in  the  internal  organs  in  the  specific  eruptions,  and 
in  the  blood  of  congenital  syphilitic  children,  but  particularly  is  its 
presence  in  the  placenta  and  in  the  umbiUcal  cord  striking,  because 
of  the  absence  of  other  organisms  in  these  situations.  In  non-leutic 
lesions  this  organism  is  always  absent.  It  also  disappears  under  the 
treatment  which  cures  S3rphins. 

Clinical  Course. — The  most  common  primary  manifestation  of 
syphilis  is  the  Hunterian  chancre,  so-called  from  its  description  by 
John  Hunter.  This  chancre  appears,  as  a  rule,  within  the  first  three 
weeks  after  infection.  It  begins  with  an  itching  in  the  affected 
part,  but  usually  is  quite  painless  and  free  from  sensitiveness  on 
pressure.  Ordinarily,  when  first  noticed,  it  appears  as  a  small  pimple, 
and  then  forms  a  brownish-red,  firm  nodule,  with  a  shallow  surface 
depression,  circular  or  oval,  and  quite  hard.  Its  edges  are  sharply 
defined,  terminating  abruptly,  and  in  this  respect  it  differs  from  ordi- 
nary inflammations.  The  surface  of  the  base  is  regular,  bright  red, 
and  on  a  level  with  the  surrounding  tissues,  while  the  center  is  often 
grayish.  The  secretion  from  it  is  scanty  and  thin,  and  suppuration 
does  not  commonly  occur.  This  sore  is  ordinarily  single,  though  oc- 
casionally multiple.  The  chancre  is  not  accompanied  by  general 
constitutional  disturbance,  and  though  the  neighboring  lymph-chan- 
nels, particularly  along  the  dorsum  of  the  penis,  are  involved,  they  are 
not  red.  Inguinal  buboes,  however,  soon  develop  in  both  groins,  but 
they  remain  discrete,  hard,  free  from  tenderness,  and  do  not  suppurate. 
In  men  the  most  common  seat  of  this  chancre  is  on  the  frenum  or  in 
the  coronal  sulcus;  in  women,  it  may  occur  anywhere  on  the  external 
genitalia.  These  are  its  most  ordinary  situations,  but  from  special 
causes  infecting  chancres  may  be  found  in  various  parts  of  the  body. 
With  the  appearance  of  the  eruption,  retrogressive  changes  in  the  chan- 
cre itself  usually  begin.  The  induration  diminishes,  the  central  por- 
tions of  the  chancre  undergo  fatty  degeneration,  and  finally  the  sore 
disappears,  though  a  scar  may  persist  and  last  for  a  long  time. 

Secondary  Stage. — After  a  lapse  of  about  four  to  eight  weeks  from 
the  appearance  of  the  chancre,  the  disease  changes  rather  suddenly 
from  a  local  to  a  general  one,  with  a  great  variety  of  constitutional 
signs  and  symptoms.  The  constitutional  symptoms  are  that  the 
patients  feel  badly,  with  a  loss  of  weight  and  strength.  Headache 
comes  on  with  the  characteristic  of  being  much  worse  at  night.  The 
tonsils  are  swollen,  and  the  throat  becomes  sore.  If  this  angina 
spreads  to  the  uvula  and  soft  palate,  the  appearance  is  almost  pathog- 
nomonic.    The  inflamed  area  is  dark  crimson,  but  abruptly  separated 


SYPHILIS  117 

from  the  healthy  mucosa  by  a  sharp  border.  Anemia  then  begins, 
sometimes  with  palpitation  and  a  sense  of  oppression  in  the  chest. 
General  enlargement  of  the  lymphatic  glands  occurs,  but  the  glands 
are  not  large,  and  they  are  painless,  hard,  discrete,  and  do  not  suppu- 
rate. The  most  frequent  of  these  glands  to  be  involved  are  the  post- 
cervical,  the  sternomastoid,  the  submaxillary,  the  epitrochlear,  and 
the  axillary. 

Fever  is  a  frequent  phenomenon  of  this  secondary  stage,  and  has 
much  the  character  of  rheumatic  fever,  accompanied  by  headache, 
nausea,  and  pain  in  the  limbs.  The  type  of  the  fever  is  usually  remit- 
tent. 

The  secondary  syphihtic  eruptions  may  be  diagnosed  by  the  fol- 
lowing common  features:  First,  they  are  usually  circular  or  nearly  so; 
their  development  is  slow,  and  successive  groups  of  eruptions  are  dis- 
similar and  more  or  less  symmetric  in  their  distribution,  with  a  reddish 
copper  color.  They  cause  no  itching,  and  are  rarely  painful.  They 
tend  to  disappear,  but  often  leave  behind  them  stains  or  scars.  They 
also  tend  to  become  generahzed  and  to  involve  large  areas  of  skin, 
being  particularly  present  on  the  forehead  and  the  extremities.  The 
dorsal  surface  of  the  hands,  wrist,  and  feet  are  exempt.  The  scales 
are  thinner,  more  superficial,  and  less  abundant  than  those  seen  in  non- 
specific lesions.  When  crusts  are  formed  they  are  greenish  brown  or 
black,  with  rough  surfaces,  and  more  easily  detached  than  in  non- 
syphilitic  lesions.     Finally,  they  are  of  different  shapes. 

The  second  stage  is  often  inaugurated  by  the  appearance  of  a 
measly,  roseolous  rash.  It  takes  place  about  the  forty-fifth  day 
after  the  appearance  of  the  chancre,  seen  first  on  the  flanks  and  sides 
of  the  thorax,  and  thence  extending  to  the  trunk  and  to  the  extensor 
surfaces  of  the  limbs.  Pressure  makes  them  disappear  only  in  the 
early  stages.  Unhke  the  exanthemata,  its  rash  comes  out  slowly,  and 
then  persists  for  several  weeks  before  it  finally  disappears.  Recur- 
rences are  not  infrequent,  and  may  be  repeated  for  several  years. 

Next  follow  the  papular  eruptions,  consisting  of  round,  reddish, 
raised  pimples,  which  may  be  of  the  diameter  of  a  ten-cent  piece. 
They  are  most  often  situated  on  the  trunk  and  face.  It  may  take  a 
form  like  Hchen.  Later,  this  papular  eruption,  which  comes  on  three 
or  four  months  after  the  onset  of  the  disease,  is  often  capped  by  a  small 
pustule  or  covered  with  crusts  which  are  arranged  in  groups,  having 
a  general  resemblance  to  psoriasis.  There  may  be  also  a  large  papular 
eruption,  particularly  about  the  natural  orifices  of  the  body,  but  they 
may  be  seen  on  the  neck,  trunk,  chin,  and  palms.     This  eruption 


Il8  CLINICAL   MEDICINE 

usually  starts  on  the  forehead,  and  then  spreads  to  the  abdomen  and 
the  rest  of  the  body,  and  may  greatly  disfigure  the  patients  by  the 
patches  running  together.  This  syphiloderm  appears  in  the  palms 
of  the  hands  and  the  soles  of  the  feet.  Fissures  and  ulcerations  are 
not  uncommon  in  it.  It  is  chronic  in  its  course,  and  obstinate  to  treat- 
ment. A  moist  papule  passes  into  the  broad  condyloma,  especially 
near  the  anus;  it  appears  like  a  fiat  button-Uke  excrescence,  elevated 
above  the  surrounding  skin  and  bathed  in  a  foul,  thin  secretion. 
Condylomata  are  much  commoner  in  women  than  in  men,  and  are 
very  contagious. 

The  large  pustular  syphiloderm  begins  as  a  large  lenticular  papule, 
which  rapidly  becomes  pustular.  The  pustule  soon  ruptures  and  dries 
up  into  a  crust.  The  lesion  usually  lasts  for  a  long  while,  the  crusts 
heaping  up  to  form  the  rupia  syphiHtica.  The  base  increases  in  size, 
and  the  lesion  in  height,  becoming  finally  cone  shaped.  The  diagnosis 
between  the  large  pustular  syphiloderm  and  variola  is  sometimes  diffi- 
cult. The  syphiloderm,  however,  makes  its  appearance  more  slowly, 
and  begins  upon  the  trunk  and  not  upon  the  face.  The  tuberculous 
syphihd  Hnks  the  preceding  eruption  with  that  of  the  gumma,  which 
does  not  usually  appear  until  about  two  years  after  the  initial  sore. 
When  it  disappears,  it  leaves  behind  it  a  marked  scar. 

Changes  in  the  Hair  and  Nails. — Alopecia  is  a  frequent  sign  of 
secondary  syphihs,  appearing  during  the  third  or  fourth  month  of  the 
disease,  often  circumscribed.  One  feature  which  is  good  for  diagnosis 
is  that  there  are  no  broken  hairs  in  the  spots.  The  eyebrows  may  be 
affected  at  the  same  time,  and  occasionally  fall  out  entirely.  The 
prognosis,  however,  is  good,  as  the  hair  grows  in  again.  Changes 
also  occur  in  the  nails,  which  may  be  cracked  or  hypertrophied. 

Lesions  of  the  Mucous  Membranes. — These  are  quite  constant  and 
important  manifestations  due  to  the  contagiousness  of  their  secretions. 
The  most  characteristic  lesion  is  the  well-known  mucous  patch,  seen 
oftenest  in  the  mouth  as  a  reddish  papular  area,  topped  by  a  small 
erosion,  occurring  at  various  places  in  the  buccal  cavity  and  quite 
often  on  the  tonsils.  Mucous  patches  often  repeatedly  recur  during 
the  course.  Their  occurrence  on  the  tonsils  and  soft  palate  is  a  point 
in  diagnosis.  The  eruption  may  involve  the  larynx,  changing  the 
voice  or  even  causing  aphonia. 

Tertiary  Syphilis. — Between  the  second  and  the  tertiary  stages 
there  is  no  sharply  marked  limit,  the  rule  being  that  tertiary  devel- 
opments occur  about  three  or  four  years  after  the  chancre.  In  many 
cases  tertiary  changes  occur  in  those  who  have  not  had  treatment. 


SYPHILIS  119 

In  general,  the  lesions  of  the  tertiary  stage  are  marked  by  lack  of 
orderly  appearance,  by  their  persistence,  by  their  non-symmetric 
arrangement,  by  their  relative  non-infectiousness,  by  their  tendency 
to  ulceration,  and  by  their  little  tendency  to  hereditary  transmission. 
Tertiary  lesions  may  occur  in  the  trachea  or  bronchi,  and  may  occa- 
sionally lead  to  serious  disorders  in  breathing. 

One  of  the  most  characteristic  of  the  tertiary  lesions  is  the  gumma. 
It  may  begin  hke  a  papule,  but  destructive  changes  are  present  which 
give  the  lesion  its  character.  First  there  is  softening  of  the  connective 
tissue,  which  is  converted  into  a  mucoid  mass.  At  first  there  are  no 
new  blood-vessels  formed,  but  later  these  become  a  feature.  The 
gumma  may  be  surrounded  by  dense  sclerotic  scar-tissue,  closely  re- 
sembling tubercle,  particularly  in  its  tendency  to  caseous  change. 
Gummata  may  be  found  anywhere.  But  in  the  Hver  they  produce 
great  destruction  of  tissue,  followed  by  extensive  fibroid  changes, 
by  which  this  organ  may  seem  to  be  tied  in  parts  as  if  with  a  rope. 
These  hver  gummata  may  even  be  mistaken  for  cancerous  tumors. 

S3^hilis  may  occasion  nephritis;  this  may  occur  early  in  the 
secondary  stage,  but  is  very  favorably  affected  by  antisyphihtic 
treatment. 

Sjrphilitic  Changes  in  the  Arteries. — This  is  the  most  common 
cause  of  death  which  can  be  traced  to  syphihs,  particularly  in  its  rela- 
tion to  the  origin  of  aneurysms.  It  may  show  itself  in  endarteritis 
of  a  gummatous  kind,  especially  in  the  arteries  of  the  brain.  Some- 
times in  the  smaller  arteries  it  takes  the  form  of  obHterative  endar- 
teritis. The  most  common  change,  however,  occurs  in  the  large 
arteries,  especially  the  aorta,  and  has  no  connection  with  ordinary 
atheroma.  The  parts  of  the  aorta  most  frequently  involved  are  the 
root  and  the  lower  part  of  the  thoracic  or  abdominal  aorta.  These 
changes  at  the  root  are  very  apt  to  involve  the  aortic  valves,  and  equally 
so  the  origins  of  the  coronary  arteries  of  the  heart.  The  recent  devel- 
opment of  an  aortic  murmur  in  a  comparatively  young  subject  without 
any  antecedent  history  of  rheumatism  is  very  suspicious  of  the  presence 
of  syphilis. 

Syphilitic  Affections  of  the  Heart. — These  may  occur  in  the  form 
of  endocarditis,  but  more  commonly  in  the  affections  of  the  walls  of 
the  heart;  in  other  words,  of  the  myocardium,  in  which  small  gummata 
are  found,  which  become  surrounded  by  fibrous  tissue.  These  fibroid 
changes  are  not  uncommonly  the  cause  of  sudden  death. 

We  may  say,  in  general,  that  only  careful,  personal  examination 
of   superficial   syphihtic   manifestations,   such   as   eruptions,   ulcera- 


I20  CLINICAL  MEDICINE 

tions,  etc.,  will  enable  one  properly  to  diagnose  the  majority  of  syphil- 
itic manifestations  of  the  heart.  Descriptions  in  books  cannot  convey 
to  the  mind  of  the  student  the  mental  pictures  upon  which  he  can 
rely,  compared  with  his  own  careful,  personal  observation. 

CoUes'  Law. — This  law,  named  after  Dr.  Abraham  Colles,  a  sur- 
geon of  Dublin,  refers  to  the  curious  fact  that  a  syphihtic  mother  may 
give  birth  to  a  child  which  may  not  show  any  signs  of  syphiHs.  Should 
the  mother  nurse  her  child,  she  will  show  no  effects  from  so  doing,  but 
should  a  healthy  woman  act  as  wet-nurse  to  this  child,  she  will  become 
infected  by  nursing  it.  This  shows  that  the  syphihtic  mother  is 
immune  to  the  infection,  but  not  one  who  has  not  been  syphiHzed. 

Cerebral  Syphilis. — Besides  the  late  parasyphilitic  affections,  such, 
as  tabes  and  general  paralysis  of  the  insane,  cerebral  syphilis  may 
occur  quite  independently  of  these  affections,  and  relatively  much, 
earlier  in  the  history  of  the  patients.  As  to  symptoms,  the  first  is 
headache,  which  is  very  intense,  with  a  tendency  to  increase  toward 
evening  and  in  the  early  morning,  while  during  .the  day  the  patient 
is  relatively  free  from  it.  I  have  rehed  upon  one  remedial  measure 
on  account  of  its  furnishing  the  clew  to  the  diagnosis,  and  that  is  to 
administer  yV  gr.  of  calomel  every  fifteen  minutes  until  six  doses  are 
taken.  This  often  greatly  relieves  the  headache,  which  it  would  not 
do  in  headache  from  any  other  cause.  This  headache  may  be  general 
or  more  or  less  limited  to  one  side  of  the  skull,  upon  which  it  is  often 
found  that  there  is  a  tender  spot  on  cranial  percussion.  This  head- 
ache may  continue  for  some  time,  until  the  onset  of  much  graver  symp- 
toms, such  as  hemiplegia,  aphasia,  or  epileptiform  attacks.  Com- 
monly associated  with  the  headache  is  insomnia. 

The  symptoms  may  arise  first  from  vascular  lesions,  causing  hemi- 
plegia and  aphasia.  Others  may  be  due  to  the  development  of  gummata 
in  the  cortex  and  in  the  subcortical  tissues.  These  are  character- 
ized by  epilepsy,  frequently  focal,  with  attacks  of  more  or  less  per- 
manent aphasia,  or  there  may  be  symptoms  due  to  meningitis,  situ- 
ated either  in  the  dura  or  in  the  pia  arachnoid,  producing  monoplegias 
or  palsy  of  one  or  more  cranial  nerves.  Occasionally  the  mental 
symptoms  are  very  grave,  due  to  diffuse  lesions  of  the  blood-vessels, 
the  patients  passing  into  a  state  of  dementia,  the  latter  being  caused 
by  actual  occlusion  of  the  cerebral  arteries,  which,  if  complete,  are 
not  recovered  from;  but  if  incomplete,  they  come  and  go  with  signs  of 
transient  hemiplegia  or  aphasia  or  mental  confusion,  lasting  only  a 
few  minutes  or  many  hours,  but  passing  off.  All  forms  of  aphasia 
may  occur  from  vascular  occlusion,  not  only  of  the  motor  type,  but 


SYPHILIS  121 

also  of  the  sensory  forms,  with  word-deafness  or  word-blindness. 
These  symptoms  point  to  disease  of  the  middle  cerebral  artery  or  its 
branches,  which  is  the  vessel  most  commonly  affected  by  syphiHtic 
arteritis.     Next  in  frequency  comes  the  basilar  artery  and  its  branches. 

Symptoms  Produced  by  Gummata. — These  are  very  similar  to  those 
of  the  brain  tumors,  and  may,  therefore,  be  either  partial  or  distinctly 
focal.  Thus,  an  epileptiform  attack  may  involve  the  leg  or  arm  or  the 
face,  or  the  whole  of  one  side  of  the  body.  It  is,  therefore,  difficult 
to  separate  symptoms  due  to  gummata  and  to  localized  syphiHtic  menin- 
gitis, because  both  conditions  are  apt  to  occur  simultaneously.  Syphil- 
itic pachymeningitis  of  the  base  is  a  common  cause  of  paralyses  of 
the  cranial  nerves,  the  nerves  most  affected  being  the  optic,  the  third, 
and  the  sixth. 

Treatment. — All  writers  agree  that  the  treatment  of  constitutional 
syphilis  cannot  begin  too  soon,  some  even  claiming  that  if  mercurial 
treatment  is  begun  when  the  presence  of  an  infecting  hard  chancre 
is  suspected  the  infection  already  present  in  the  blood  and  just 
beginning  to  show  signs  of  a  syphilitic  exanthem  may  be  arrested  in 
its  course  then  and  there.  For  this  purpose  Mr.  Jonathan  Hutchin- 
son's line  of  treatment  might  be  adopted,  of  i  gr.  of  hydrargyrum  cum 
creta,  given  in  pill,  in  combination  with  ^  gr.  of  opium,  so  as  to  pre- 
vent diarrhea.  The  two  complications  during  this  treatment  to  be 
avoided  are  salivation  and  diarrhea.  The  salivation  may  be  best 
prevented  by  cleansing  the  mouth  and  the  use  of  alum  mouth-wash. 
This  pill  should  be  given  four,  five,  six,  or  seven  times  a  day,  without 
regard  to  meal-time.  All  soups,  green  vegetables,  fruit,  beers,  and 
wines  should  be  strictly  forbidden.  As  a  rule,  Dover's  powder  appears 
to  be  more  effective  in  preventing  diarrhea  than  its  equivalent  of 
opium.  This  treatment  should  be  carried  out  for  twelve  months  with- 
out any  intermission. 

After  twelve  months  the  doses  may  be  decreased  in  number,  but 
still  continued  for  another  year  to  prevent  relapses.  I  have  myself 
pursued  a  similar  treatment  by  giving  ^  gr.  of  calomel  four  times  a 
day,  increasing  the  dose  by  2V  g^-  every  day  until  the  bowels  become 
loose,  whereupon  the  dose  should  be  decreased  until  the  patient 
is  no  longer  so  affected.  That  dose  which  does  not  produce  any  symp- 
toms is  then  taken  as  the  standard  dose  for  that  patient,  and  should 
be  continued  for  two  years.  If  the  patient  should  first  come  under 
observation  some  time  after  infection,  his  particular  dose  of  mercury, 
shown  by  the  same  procedures  as  above  mentioned,  should  be  found 
out  and  then  followed  as  before  detailed.     Another  method  of  mercurial 


122  CLINICAL   MEDICINE 

treatment  is  by  mercurial  inunction.  In  this  treatment  i  dram  of  the 
ordinary  blue  ointment  should  be  rubbed  into  the  skin  every  night, 
beginning  with  the  surface  on  one  side  of  the  thorax,  and  on  the  suc- 
ceeding night  by  a  hke  appHcation  on  the  other  side.  After  that  the 
appHcation  can  be  made  on  the  surface  of  the  inner  aspect  of  each 
thigh  alternately,  and  then  return  to  the  original  place  on  the  thorax, 
the  reasons  for  these  intermittent  apphcations  being  that  a  too  con- 
tinuous use  of  this  ointment  at  one  place  is  likely  to  cause  severe  irri- 
tation of  the  skin.  When  a  rapid  effect  of  the  drug  is  desirable,  as  in 
iritis  or  in  situations  where  the  syphiHtic  lesion  is  dangerous,  the  mer- 
curial vapor-bath  may  be  used,  according  to  the  directions  given  in 
text-books. 

In  syphihtic  diseases  of  the  nervous  system,  I  invariably  use  intra- 
muscular injections  of  the  corrosive  sublimate,  as  I  have  found  these 
injections  to  succeed  much  better  than  any  other  modes  of  adminis- 
tering mercury  for  these  particular  infections.  The  injections  consist 
of  I  to  f  gr.  of  corrosive  subHmate  dissolved  in  20  min.  of  distilled  water. 
The  needle  of  the  hypodermic  syringe  should  be  passed  directly  into 
the  substance  of  the  gluteus  muscle,  for  there  it  causes  but  Uttle  pain, 
which  it  would  do  if  it  were  injected  into  the  tissues  just  under  the 
skin.  These  injections  should  be  repeated  once  or  twice  a  week.  In 
the  London  Lock  Hospital  similar  injections  are  used  for  all  forms  of 
syphilitic  infections,  chiefly  on  account  of  their  greater  convenience 
to  the  patients.  Corrosive  sublimate  is  much  less  liable  than  other 
forms  of  mercury  to  produce  either  sahvation  or  diarrhea. 

For  tertiary  lesions,  or  for  those  involving  the  periosteum  in  the 
later  stages  of  secondary  disease,  the  iodid  of  potassium  has  long  held 
a  deservedly  prominent  place.  The  preparations  of  iodin  cannot  be 
described  as  truly  curative  of  syphihs,  but  they  are  remarkably  effect- 
ive in  relieving  syphilitic  exudations  in  the  fibrous  tissues,  whether  in 
the  later  secondary  or  in  the  tertiary  stages.  The  dose  of  the  potas- 
sium iodid  is  to  be  gaged  solely  by  its  remedial  effects,  some  late 
tertiary  lesions  requiring  very  large  doses,  such  as  140  to  240  gr.  per 
day.  In  early  syphilitic  periostitis  with  severe  pains  10  to  20  gr. 
three  times  a  day  may  be  given  along  with  doses  of  opium  and  fluid- 
extract  of  conium.  The  doses,  however,  should  be  regulated  by  the 
patient's  abihty  to  bear  iodin  in  its  various  forms,  and  they  should 
be  diminished  as  soon  as  the  patient  shows  signs  of  iodism.  This  is 
made  plain  by  a  catarrhal  affection  of  the  mucous  membrane  of  the 
nose  and  throat  as  well;  sometimes,  by  a  disturbance  of  the  stomach, 
patients  becoming  feverish  along  with  symptoms  of  general  debility. 


SYPHILIS  123 

With  some  patients  signs  of  ioclism  are  caused  by  small  doses,  in  which 
case  the  idiosyncrasy  of  the  patient  seriously  militates  against  his 
rehef.  Preparations  of  iodin  and  mercury  are  very  often  combined,  not 
in  the  same  prescription,  but  rather  taken  together,  constituting  what 
is  called  mixed  treatment.  Thus,  I  have  found  pills  of  the  biniodid 
of  mercury,  from  2^5^  to  ^V  g^v  of  service  in  cerebral  syphilis,  combined 
with  counterirritation  at  the  nape  of  the  neck  by  application  of  the 
biniodid   of  mercury  ointment  at  night  until  the  spot  becomes  sore. 

One  of  the  greatest  discoveries  of  modern  times  we  owe  to  the 
genius  of  Paul  Ehrhch.  Recognizing  that  syphiHs  is  due  solely  to 
the  multiplication  in  the  body  of  Schaudinn's  protozoon,  the  Spirochasta 
pallida,  EhrHch  made  extended  researches  for  the  discover}^  of  a  spe- 
cific poison  for  this  organism,  finally  settling  upon  a  substance  which 
he  termed  "Number  606,"  to  represent  his  last  experiment.  This 
agent  ("606")  should  be  termed  dioxydiamido-arsenobenzol  to  represent 
its  true  chemical  composition.  As  this  name  was  altogether  too  long 
to  be  readily  pronounced,  it  is  now  generally  termed  salvarsan.  It 
is  administered  by  injection,  preferably  into  a  vein,  because  when 
introduced  either  into  deep  muscular  tissue  or  subcutaneously  it 
causes  great  pain,  and  sometimes  actual  sloughing.  Nothing  could 
exceed  the  prompt  efhcacy  of  this  injection,  the  most  serious  ulcera- 
tions, whether  of  secondary  or  of  tertiary  lesions,  healing  with  mar- 
velous rapidity.  It  was  natural,  therefore,  that  it  should  at  first  be 
hailed  as  the  long-sought-for  specific  against  syphiHs,  and  doing  away 
with  every  other  treatment,  including  that  of  mercury;  but  ere  long 
it  was  found  that  relapses  sooner  or  later  occurred  which,  with  some, 
served  to  discredit  its  use,  and  the  claim  was  made  that  we  had  no 
trustworthy  agent  against  syphilis  except  mercury.  The  true  causes 
for  these  relapses,  however,  are  not  properly  understood.  We  have 
no  knowledge  of  the  Hfe-history  of  the  Spirochaeta  paUida,  and  there 
can  be  no  doubt  that  it  may  pass  through  hitherto  undiscovered  larval 
forms,  which  may  survive  the  poisoning  by  salvarsan  of  the  adult 
forms  of  the  organism.  We  have  a  number  of  illustrations  of  this  in 
other  infectious  organisms,  and  while  we  may  doubt  that  salvarsan 
may  wholly  supplant  mercury  in  the  treatment  of  syphiHs,  yet  it  may 
be  of  essential  service  by  repeated  administrations  in  finally  ridding 
the  system  of  this  organism. 

Further  experience  has  demonstrated  the  advisabiHty  of  combining 
the  administration  of  salvarsan  with  a  true  mercurial  treatment,  which 
ensures  recovery  much  more  certainly  than  either  salvarsan  or  mercury 
alone. 


124  CLINICAL  MEDICINE 

Salvarsan,  however,  has  certain  serious  drawbacks.  Its  adminis- 
tration was  apparently  more  effective  when  given  deep  into  muscular 
tissues,  as  in  the  substance  of  the  gluteus  maximus  muscle,  than  when 
given  intravenously;  but  when  injected  into  the  muscular  tissue  it 
was  apt  to  produce  very  severe  pain  accompanied  by  inflammation 
and  even  abscess  at  the  site  of  the  injection.  It  was  a  great  gain, 
therefore,  when  Ehrlich  announced  the  discovery  of  the  preparation 
which  he  called  neosalvarsan,  and  which  now  has  quite  superseded 
the  original  salvarsan  in  practice.  Ehrlich  claims  that  neosalvarsan 
is  superior  to  the  original  salvarsan  in  the  following  particulars:  (i) 
High  solubility;  (2)  neutral  reaction;  (3)  low  toxicity;  (4)  therapeutic- 
ally as  effective,  if  not  more  so,  than  salvarsan  itself;  (5)  it  does  not 
cause  reaction  symptoms,  such  as  diarrhea  and  vomiting,  even  after 
large  doses.  The  bulk  of  neosalvarsan  is  greater  than  that  of  salvar- 
san, 0.9  gm.  of  neosalvarsan  corresponding  to  0.6  gm.  of  salvarsan. 
In  administration  of  neosalvarsan  for  intramuscular  injections  o.i 
gm.  of  neosalvarsan  is  dissolved  in  180  c.c.  of  water,  which  has  been 
distilled  on  the  same  day,  then  sterilized  and  cooled  to  room  tempera- 
ture. As  previously  remarked,  all  preparations  of  salvarsan  are  im- 
mediately destructive  of  the  life  of  any  kind  of  spirochete,  and  hence 
are  constantly  used  against  trympanosomiasis  in  all  its  forms. 

The  average  single  dose  of  neosolvarsan  for  men  is  0.75  to  0.9 
gm.;  for  women,  0.6  to  0.75  gm.  This  may  be  repeated  according  to 
its  effect,  and  in  some  cases  it  may  require  to  be  repeated  at  intervals 
of  a  week  for  three  months  to  prevent  relapses. 

TABES  DORSALIS— PARASYPHILITIC  AFFECTIONS 

As  a  rule,  these  are  the  latest  manifestations  of  syphilitic  taint, 
occurring  most  strikingly  in  chronic  nervous  affections,  such  as  tabes 
and  paresis,  or  general  paralysis  of  the  insane.  Tabes,  commonly 
called  locomotor  ataxia,  is  the  most  noted  of  these  affections.  At 
first  it  was  vehemently  denied  by  eminent  neurologists  that  syphilis 
had  anything  to  do  with  the  genesis  of  tabes,  but  of  recent  years  the 
opinion  is  gaining  ground  that  cases  of  true  tabes  without  syphilitic 
infection  are  rare.  Erb  says  that  syphilis  is  the  antecedent  of  90 
per  cent.  All  agree,  however,  that  other  factors,  such  as  exposure  to 
cold  or  fatigue,  or  similar  debihtating  agencies,  predispose  to  develop 
the  disease  in  those  who  have  the  luetic  taint.  The  same  may  be  said 
of  the  dementia  paralytica  or  the  general  paralysis  of  the  insane.  The 
pecuKarity  of  these  paras3rphihtic  affections  is  that  they  hardly,  if 
at  all,  are  amenable  to  the  usual  antisyphilitic  remedies. 


TABES    DORSALIS — PARASYPHILITIC   AFFECTIONS  1 25 

The  hard  infecting  chancre  of  Hunter  is  by  no  means  the  only 
venereal  sore.  There  is  also  what  has  been  very  properly  called  a  soft 
chancre,  termed  by  some  "cancroid."  This  sore  occurs  nearly  as  often 
as  a  true  chancre,  but  fundamentally  differs  from  the  latter  in  that  it 
does  not  infect  the  general  system.  As  its  name  soft  chancre  impUes, 
it  is  not  indurated  and  its  edges  are  not  sharply  defined.  It  may,  how- 
ever, produce  the  most  extensive,  and  sometimes  dangerously  slough- 
ing ulcers,  characterized  by  an  abundant  discharge  of  pus.  It  also 
involves  the  inguinal  glands,  more  commonly  on  one  side,  which 
enlarge  and  form  abscesses  called  suppurating  buboes,  but  does  not 
infect  the  general  system.  Unfortunately,  no  one  can  be  sure  from  the 
characters  of  the  initial  sore  that  it  is  not  an  infecting  chancre,  because 
constitutional  infection  has  occurred  in  many  cases  of  apparently  soft 
chancres,  so  that  it  is  probable  that  an  infecting  chancre  mil  grow  on 
a  soft  chancre.  The  suppurating  buboes  leave  permanent  scars  in  the 
groins,  whose  presence  may  be  of  service  in  showing  that  the  patient 
has  not  a  general  syphiUtic  infection. 

The  treatment  of  this  soft  chancre  by  no  means  corresponds  to  the 
treatment  of  true  syphihs,  for  it  is  fundamentally  different  from  a 
syphilitic  infection  of  any  form.  It  should  be  treated  by  appropriate 
caustics,  which  will  change  it  into  an  ordinary  cutaneous  sore.  The 
directions  for  this  belong  more  properly  to  books  on  surgery. 

Clinical  Symptoms. — Of  the  cHnical  symptoms  of  tabes  the  earhest 
are  its  characteristic  pains.  They  are  sometimes  called  "lightning 
pains"  and  usually  begin  in  the  lower  extremities.  These  pains  are 
paroxysmal,  beginning  suddenly  and  darting  down  the  affected  hmb. 
As  previously  described  in  the  chapter  on  Pain  the  gestures  of  the 
patient  are  characteristic,  using  the  index-finger  to  indicate  how  they 
shoot  down  the  limb.  Another  feature  never  present  in  inflammatory 
pain  is  that  the  patient  forcibly  grasps  the  limb  as  if  thus  to  arrest  it. 
Occasionally,  instead  of  being  shooting  in  character,  it  is  located  in  a 
part  of  the  bone  usually  just  above  the  ankle,  and  is  then  of  a  boring 
character,  as  if  the  part  had  an  auger  passing  through  the  bone.  These 
pains  may  first  affect  the  Hmb  of  one  leg  and  then  the  other,  or  the 
arm  and  leg  of  one  side  or  of  both  sides.  The  patients  often  complain 
that  Hfe  is  rendered  miserable  by  their  existence.  I  have  known  tabetic 
pains  to  set  in  as  early  as  the  third  month  after  the  infection,  but  usu- 
ally they  are  much  later  in  their  manifestations.  On  examining  the 
skin  with  an  esthesiometer  or  with  a  simple  pin-prick,  irregular  areas 
of  total  anesthesia  may  be  found  which  have  no  parallel  in  any  other 
disease. 


126  -  CLINICAL  MEDICINE 

This  is  the  place  for  alluding  to  a  very  striking  character  of  tabes, 
namely,  the  loss  of  knee-jerk.  Normally,  if  one  leg  is  crossed  over  the 
other,  on  striking  the  tendon  of  the  quadriceps  as  it  crosses  the  patella, 
the  leg  with  the  foot  is  thrown  forward,  particularly  if  at  the  same  time 
with  the  stroke  both  fists  are  clenched.  In  certain  spinal  cord  affec- 
tions this  kick  of  the  leg  is  much  exaggerated,  but  in  tabes  it  is  wholly 
absent.  Other  affections,  however,  are  characterized  by  loss  of  the  knee- 
jerk,  particularly  in  diabetes  melHtus,  and  very  often  the  same  absence 
of  knee-jerk  occurs  at  advanced  age.  The  value,  however,  of  the  ab- 
sence of  the  patella  reflex  in  tabes  is  that  this  symptom  is  then  not 
alone,  but  accompanied  by  equally  characteristic  changes  in  the  pupil 
of  the  eye.  In  some  cases  of  tabes  both  pupils  are  symmetrically  con- 
tracted; more  commonly,  however,  one  is  contracted  and  the  other  is 
not,  or  even  dilated,  but  whatever  their  condition  be  the  pupils  are 
wholly  insensible  to  hght.  It  is  then  the  presence  of  the  symptom 
called  Argyll-Robertson  sign  is  so  valuable,  for  though  the  pupils  are 
insensible  to  Hght  they  will  dilate  or  contract  according  to  accommo- 
dation. In  health  when  an  object  is  brought  near  the  eye,  the  pupil 
dilates  as  the  object  is  approximated  and  contracts  as  the  object  re- 
cedes, but  in  tabes  this  change  in  accommodation  is  preserved,  though 
otherwise  the  pupil  is  insensible  to  light. 

Besides  the  characteristic  pains  of  this  disease,  other  equally  import- 
ant symptoms  develop  in  the  action  of  the  muscles.  This  consists  not 
in  weakness  or  paralysis,  but  in  a  special  derangement  of  muscular  co- 
ordination, from  which  it  gets  the  name  locomotor  ataxia.  This 
incoordination  strikingly  resembles  the  irregular  movements  of  a 
drunkard,  and  is  due  to  the  same  paralysis  or  absence  of  what  we  call 
the  muscular  sense  when  there  is  no  paralysis  of  the  muscles.  By  this 
muscular  sense  the  brain  is  informed  of  the  state  of  the  muscles,  and 
knows  how  to  coordinate  the  necessary  movements  in  the  perform- 
ance of  every  muscular  act.  When  the  muscular  sense  is  absent,  both 
in  the  drunkard  and  the  tabetic,  the  patient  does  not  know  the  where- 
abouts of  his  legs  or  even  of  his  arms,  and  thus  both  staggers  in  his 
gait  and  finds  himself  incapable  of  performing  the  simplest  act,  such 
as  buttoning  clothes  or  tying  his  shoe-strings.  The  difference,  how- 
ever, between  the  tabetic  and  the  drunkard  is  easily  demonstrated— 
the  tabetic  is  obliged  especially  to  use  his  eyes.  If  he  is  standing  and 
closes  his  eyes  he  sways  from  side  to  side  or  actually  falls  to  the  ground. 
He,  therefore,  never  can  lift  his  eyes  from  his  feet  while  walking,  nor 
is  he  able  to  walk  in  the  dark.  His  gait  is  almost  decisive  of  the  pres- 
ence of  his  disease,  for  he  brings  his  heels  down  heavily  first,  so  as  to 


TABES    DORSALIS — PARASYPHILITIC    AFFECTIONS  1 27 

communicate  the  jar  to  the  spine,  and  it  is  not  until  this  is  done  that 
the  rest  of  the  foot  will  follow;  but  the  ataxia  is  equally  present  in 
the  arms.  Tell  him  to  bring  the  tips  of  the  fingers  of  both  hands  to- 
gether and  he  cannot  do  so  if  his  eyes  are  closed,  the  fingers  passing  one 
another  in  attempting  the  act.  Also,  when  asked  to  touch  the  tip  of 
his  nose  with  his  index-finger  when  his  eyes  are  closed,  he  may  touch 
instead  his  cheek  or  his  ear.  One  of  the  earliest  signs  of  this  ataxia 
is  present  in  his  handwriting.  He  cannot  keep  on  the  same  fine,  and 
the  down-strokes  are  much  more  pronounced  than  the  up-strokes. 
Ask  him  to  put  a  pin  through  a  sheet  of  paper,  and  he  does  so  with  un- 
necessary force  even  though  his  eyes  are  open.  As  the  disease  pro- 
gresses the  muscular  incoordination  increases,  so  that  the  patient  is 
no  longer  able  to  walk  and  has  to  remain  in  bed,  while  he  is  so  uncertain 
as  to  the  position  of  his  Hmbs  that  he  has  to  be  w^atched  to  prevent 
them  from  being  thrown  out  from  under  the  bedclothes.  Meantime,  it 
should  be  borne  in  mind  that  the  muscles  are  not  paralyzed  any 
more  than  those  of  a  drunkard.  It  is  only  that  they  cannot  be  made 
to  work  together. 

Disturbances  of  sensation  are  apt  to  accompany  the  muscular 
incoordination,  and  here  also  these  usually  begin  in  the  lower  limbs. 
The  patient  has  sensations  of  tingling,  pins  and  needles,  or  numbness, 
and  when  walking  he  may  feel  as  if  he  were  treading  on  cotton-wool. 
About  the  trunk  also  he  may  have  a  girdle  pain  like  the  sensation  of  a 
cord  tied  tightly  about  the  body.  Examination  may  then  show  that 
there  are  various  degrees  of  loss  of  sensation  on  the  surface,  such  as 
inabihty  to  feel  the  prick  of  a  pin,  or  if  he  does,  that  the  sensation  of 
pain  is  delayed  in  its  transmission  to  the  brain.  Along  with  this  the 
sensation  of  posture  may  be  lost,  so  that  he  cannot  tell  how  his  legs 
are  placed  without  looking  at  them.  Likewise,  he  may  be  unable  to 
discriminate  the  difference  of  weights  placed  in  his  hands.  The  ataxia 
usually  slowly  gets  worse,  spreading  upward  to  hands  and  arms. 
Meanwhile  the  most  obvious  disturbance  of  sensation  is  in  the  darting, 
so-called '  lightning  pains"  already  referred  to.  These  shoot  usually  from 
above  downward  and  are  often  very  severe.  Sometimes  the  Hghtning 
pains  disappear  as  the  disease  advances,  but  the  signs  of  the  pupil 
and  the  absence  of  the  knee-jerk  remains.  Disturbances  of  the  action 
of  the  bladder  in  micturition  may  occur  early  in  the  disease,  and  take 
the  form  first  of  inability  to  start  the  stream,  and  then  of  irregular 
checking  of  the  flow.  Often  after  the  patient  has  thought  that  he 
had  finished  micturition,  an  immediate  desire  to  pass  water  may  set 
in,  in  which  his  efforts  may  or  may  not  be  successful.     Sometimes  these 


128  CLINICAL  MEDICINE 

attacks  are  called  "vesical  crises."  As  the  disease  progresses,  paralysis 
of  the  bladder  may  become  complete.  The  sexual  impotency,  which 
may  have  been  preceded  by  undue  sexual  excitement,  becomes  com- 
plete. The  patient  may  finally  be  confined  to  his  bed,  being  unable  to 
walk,  and  is  then  likely  to  have  bed-sores  and  inflammation  of  the 
bladder.  Other  characteristic  changes  also  occur.  Muscular  weak- 
ness may  be  general  or  local.  Paralysis  of  the  ocular  muscles  may 
develop  from  affection  of  the  third  nerve  or  one  or  more  of  its  branches. 
One  superior  obUque  may  be  paralyzed,  either  partially  or  totally, 
and  yet  after  a  while  recover  again,  though  not  always.  Occasionally, 
these  ocular  palsies  may  be  bilateral,  as  for  example,  double  ptosis. 
These  transient  palsies  are  usually  syphilitic,  but  it  should  be  remem- 
bered that  they  may  be  difficult  to  discriminate  from  disseminated 
sclerosis,  a  disease  with  which  syphilis  has  nothing  to  do.  Occasion- 
ally, tabetics  show  some  of  the  symptoms  of  hemiplegia  along  with 
epileptiform  fits,  or  attacks  of  vertigo  with  coma.  Their  transient 
character,  however,  shows  them  to  be  of  tabetic  origin.  Local  paraly- 
sis may  also  occur  in  other  nerves,  such  as  the  radial,  ulnar,  and  peroneal 
nerves.  Paralysis  of  one-half  of  the  tongue  may  be  due  either  to  the 
paralysis  of  the  hypoglossal  nerve  or  of  its  nucleus.  Occasionally, 
the  muscles  may  be  so  weakened  in  their  tone  that  they  allow  stretch- 
ing beyond  anything  normal. 

Relation  to  the  Special  Senses  in  Tabes. — Complete  deafness  may 
be  caused  by  tabes,  but  affections  of  the  ear  are  not  so  common  as  those 
of  the  eye,  in  which  the  optic  nerve  atrophies.  This  is  sometimes  an 
early  sign,  and  is  estimated  by  some  as  15  per  cent,  of  the  cases  of 
tabes.  I  had  i  patient  referred  to  me  who  was  completely  bhnd  from 
this  optic  atrophy,  but  who  could  walk  without  any  ataxia.  The 
patient  first  notes  his  failure  of  vision  in  one  eye,  and  then  after  that  in 
the  other,  the  trouble  progressing  until  it  ends  in  complete  blindness. 
Occasionally,  a  progressive  paralysis  of  the  external  ocular  muscles 
occurs  until  it  becomes  complete.  Like  the  optic  atrophy,  this  is  an 
early  sign.  It  may  begin  with  ptosis,  first  of  one  eyelid,  then  of  both. 
This  is  frequently  accompanied  by  external  squint  caused  by  paralysis 
of  the  sixth  nerve. 

Visceral  Crises. — The  commonest  of  these  in  tabes  is  the  gastric 
crisis,  pain  beginning  in  the  epigastrium,  then  nausea,  and  soon 
vomiting  of  a  most  severe  and  intractable  character,  and  nothing  will 
stay  on  the  stomach,  though  the  tongue  is  clean  and  the  temperature 
normal.  After  lasting  for  two  or  several  days,  accompanied  by  great 
prostration,  the  vomiting  suddenly  ceases,  leaving  the  patient  very 


TABES    DORSALIS — PARASYPHILITIC   AFFECTIONS  1 29 

weak.  These  gastric  crises  are  usually  early  in  their  appearance,  and 
pass  off  as  the  disease  progresses.  Sometimes  the  crises  are  intestinal, 
shown  by  attacks  of  diarrhea,  or  the  patient  has  attacks  of  tenesmus, 
with  pains  in  the  rectum.  There  are  also  laryngeal  crises,  due  to  a 
bilateral  affection  involving  the  abductor  muscles  only,  when  the  cords 
may  approach  gradually  nearer  to  the  middle  Une  until  the  glottis  is 
reduced  to  a  mere  chink.  Such  a  patient  is  evidently  in  constant 
danger,  and  a  tracheotomy  may  be  required  at  any  moment,  yet  occa- 
sionally some  patients  are  but  httle  discommoded,  though  the  glottis 
is  considerably  narrowed. 

Circulatory  System. — Frequency  of  the  pulse  nearly  always  is 
present  in  tabes.  Attacks  resembUng  angina  pectoris  may  occur,  and 
have  been  called  cardiac  crises. 

Trophic  Lesions. — Probably  the  most  serious  of  the  accompaniments 
of  tabes  are  the  pecuHar  affections  of  the  joints  and  bones.  Thus,  a 
knee-joint  may  be  wholly  disorganized  by  a  sudden  attack  of  what  is 
called  Charcot's  disease.  The  joint  first  swells  to  a  great  degree,  but 
without  any  inflammatory  appearance  or  pain.  Not  long  after- 
ward it  is  found  that  the  bony  surfaces  making  up  the  joint  are  wholly 
disorganized,  the  ends  of  both  the  femur  and  tibia  Hterally  going  to 
pieces,  with  fragments  of  bone  scattered  through  the  exudation,  with  a 
remarkable  feature  that  the  joint  disease  is  wholly  unaccompanied 
with  pain,  the  patient  first  noticing  the  trouble  from  his  inability  to 
walk.  Along  with  this  the  bones  become  very  fragile,  so  that  the  mere 
act  of  turning  in  bed  may  be  enough  to  break  the  thigh  bone.  This 
affection  of  the  joints  and  bones  may  come  on  early  before  the  s>Tnp- 
toms  of  ataxia.  The  fractured  ends  usually  set  about  to  repair,  much 
as  in  other  fractures,  except  that  the  amount  of  callus  may  be  dispro- 
portionately great,  so  as  to  resemble  a  tumor.  Other  irregularities 
may  then  set  in.  In  certain  places  great  atrophy  of  the  bony  struc- 
tures occurs,  while  with  others  hypertrophy  follows  instead,  produc- 
ing extensive  osteophytes.  Occasionally,  the  ease  with  which  the 
bones  may  be  broken  is  extraordinary,  as  in  a  case  mentioned  by 
Foquet,  in  which,  on  trying  to  extract  a  tooth,  the  whole  alveolar  process 
came  away.  These  bony  derangements  in  tabetics  may  be  multiple, 
for  in  I  case  there  were  seven  fractures.  In  about  75  per  cent,  of  the 
cases  in  tabes  the  joints  affected  belong  to  the  lower  extremities.  It 
is  curious  how  often  all  premonitory  symptoms  are  absent.  These 
affections  of  the  joints  and  bones  are  closely  imitated  by  the  results  of 
syringomyelia,  but  in  this  latter  affection  the  joints  of  the  upper 
extremity  are  much  more  likely  to  be  involved  than  the  lower.  An- 
9 


I30 


CLINICAL  MEDICINE 


other  serious  result  of  this  complaint  is  a  perforating  ulcer  of  the 
foot,  which  may  also  come  on  early.  It  begins  as  a  corn,  seated  usu- 
ally on  the  ball  of  the  great  or  of  the  Kttle  toe.  Under  this  suppura- 
tion occurs,  and  ulceration  which  may  extend  into  the  joints.  Occa- 
sionally the  results  are  not  so  serious,  and  the  ulcer  spontaneously 
gets  well. 

Morbid  Anatomy. — In  tabes  the  commonest,  most  obvious  ana- 
tomic change  is  the  degeneration  of  the  posterior  spinal  roots  and  the 
posterior  columns  of  the  cord.  On  opening  the  spinal  canal  it  will  be 
observed  that  the  pia-arachnoid  is  thickened  over  the  posterior  sur- 
face of  the  cord,  while  the  posterior  roots  are  thin,  flattened,  and  atro- 
phied. The  posterior  columns  are  considerably  shrunken,  and  are 
grayish  in  color,  contrasting  strongly  with  the  white  anterolateral 
columns.  Likewise,  the  posterior  roots  entering  into  the  formation  of 
the  Cauda  equina  are  atrophied  to  a  greater  degree  than  elsewhere. 
Normally,  the  posterior  roots  are  two  or  three  times  as  large  as  the 
anterior,  but  in  advanced  cases  of  tabes  they  waste  to  such  a  degree 
as  to  be  even  smaller.  Besides  this,  various  cranial  nerves  may 
be  atrophied.  The  gray  atrophy  of  the  optic  nerve  is  obvious  to  the 
naked  eye,  but  many  peripheral  nerves  also  show  degeneration.  Mi- 
croscopic examination  of  the  spinal  cord  shows  the  myelin-sheath  of  the 
nerves  destroyed.  The  axis-cyhnder  process  may  be  very  irregular, 
swollen  in  one  place,  or  completely  atrophied  in  another.  The  neurog- 
lia is  increased  at  the  expense  of  the  parenchyma.  The  walls  of  the 
blood-vessels  are  often  thickened  in  the  sclerosed  area  and  not  else- 
where. Sometimes  the  vessels  are  so  much  thickened  as  to  become 
almost  obliterated.  The  pia-arachnoid  membrane  is  also  thickened, 
as  if  from  chronic  inflammation. 

The  spinal  degeneration  in  tabes  corresponds  to  the  intraspinal 
distribution  of  the  nerve-roots.  These  roots  on  entering  the  cord 
divide  into  ascending  and  descending  fibers.  Degeneration  of  the 
fibers  connecting  the  posterior  roots  with  the  anterior  cornua  would 
account  for  the  loss  of  the  reflex  tone  in  the  muscles  and  for  the  loss 
of  the  knee-jerk.  Other  fibers  from  the  posterior  roots  run  for  a  short 
distance  upward  and  then  turn  into  the  gray  matter.  Around  the 
cells  are  Clarke's  columns.  They  also  degenerate  in  tabes,  and,  as 
Clarke's  columns  are  the  origin  of  the  ascending  cerebeflar  tracts, 
this  degeneration  cuts  off  one  route  to  the  cerebellum,  which  may  give 
rise  to  disturbances  of  equilibrium.  Research  shows  that  the  posterior 
ganghon  is  by  no  means  so  much  impHcated  as  the  posterior  root. 
Many  hypotheses  have  been  advanced  to  account  for  the  involvement 


TABES    DORSALIS — PARASYPHILITIC   AFFECTIONS  131 

of  the  posterior  roots  in  tabes,  but  none  of  them  explain  all  the  facts. 
Thus,  degeneration  of  the  peripheral  nerves  supplying  the  skin,  bones, 
joints,  etc.,  and,  above  all,  optic  atrophy,  cannot  be  explained  on  any 
of  these  h3q3otheses.  In  addition,  there  may  be  a  locaUzed  paralysis 
and  a  progressive  opthhalmoplegia  due  to  degeneration  of  the  ocular 
motor  nuclei.  All  these  considerations  show  that  the  morbid  process 
in  tabes  is  of  a  general  nature,  and  not  a  local  lesion  of  the  posterior 
nerve-roots.  It  may  be  said,  therefore,  that  syphiUs  produces  a  toxin 
which  may  act  on  the  nervous  system  in  general,  but  which  has  a  pri- 
mary particular  action  on  the  posterior  root  neurons. 

Treatment. — We  have  already  stated  that  parasyphilitic  affections, 
whether  tabes  or  paresis,  seem  not  to  be  amenable  to  antisyphilitic 
remedies.  Recently,  however,  the  treatment  of  these  parasyphihtic 
disorders  by  salvarsan  and  neosalvarsan  has  been  stated  to  be  more 
or  less  efficacious.  Time  only  will  show  whether  this  be  true  or  not, 
but  in  these  otherwise  hopeless  affections  it  may  be  well  to  try  salvar- 
san administered  intravenously. 

As  to  tabes  itself  we  are  obliged  to  attend  first  of  all  to  the  allevia- 
tion of  the  hghtning  pains.  For  this  purpose  there  can  be  no  doubt 
that  we  have  valuable  agents  in  the  coal-tar  series,  such  as  antipyrin 
and  phenacetin.  Phenactin  is  the  least  depressing  of  them  all,  and 
there  is  no  case  on  record  of  any  fatahty  following  upon  its  administra- 
tion, however  large  the  dose.  It  may  be  well  to  combine  each  dose 
with  from  i  to  2  gr.  of  caffein  citrate  with  4^  gr.  of  strychnin.  I  have 
thought  that  application  of  the  actual  cautery  in  a  special  form  has 
done  good.  This  is  best  done  by  heating  the  tip  of  an  ordinary  glass 
tube  to  redness  in  the  flame  of  an  alcohol  lamp  and  then  quickly  apply- 
ing it  to  spots  along  the  spinal  column,  when,  if  done  properly,  the 
external  epidermis  snaps  on  application.  The  tip  of  the  tube  should 
never  be  allowed  to  remain  long  enough  to  make  a  sore,  and  the  appH- 
cation  may  be  begun  at  the  neck  at  intervals  of  i  inch  apart  for  10 
inches.  After  this  procedure  a  continuous  red  line  joins  aU  the  spots 
touched.  The  next  apphcation  should  be  after  an  interval  of  three 
days,  and  thus  continued  until  the  whole  spinal  column  has  been  trav- 
ersed. I  once  had  a  patient  cauterized  in  this  manner  4800  times, 
the  operations  being  done  by  his  wife,  this  counterirritation  constantly 
reheving  his  tabetic  pains. 

In  addition  to  the  treatment  of  tabetic  pains  which  we  have  already 
mentioned,  something  may  be  done  to  improve  the  nutrition  of  the 
spinal  cord.  The  only  medicines  which  have  any  testimony  in  their 
favor  are  arsenic,  preferably  in  the  form  of  the  cacodylate  of  soda,  of 


132  CLINICAL  MEDICINE 

which  I  gr.  may  be  given  three  times  a  day.  Care  should  be  taken, 
however,  not  to  produce  even  the  earhest  symptoms  of  overdosing 
with  arsenic.  Those  symptoms  would  be  a  sense  of  weight  at  the 
epigastrium  after  eating,  and  then  pufiiness  of  the  eyehds,  sometimes 
with  numbness  and  tinghng  in  the  fingers. 

In  former  times  nitrate  of  silver  enjoyed  some  repute  in  the 
treatment  of  degenerative  diseases  of  the  spine,  I  think  that  it  still 
deserves  to  be  reckoned  as  a  restorative  agent  in  such  diseases.  Thus, 
I  had  a  case  of  a  patient  who  suffered  from  an  organic  difficulty 
in  his  sacrum  due  to  the  pressure  of  a  small  tumor  involving  the 
anterior  root  of  the  first  sacral  nerve.  The  consequent  pain  had  the 
pecuHarity  of  coming  on  in  the  late  afternoon  and  continuing  through 
the  night.  In  him  this  pain  was  markedly  reheved  by  the  adminis- 
tration of  a  pill  containing  i  gr.  of  silver  nitrate.  He  had  no  idea  what 
he  was  taking,  but  so  soon  as  the  pill  had  to  be  intermitted,  lest  its  too 
long  continuance  would  cause  discoloration  of  the  skin,  he  at  once  knew 
that  something  which  afforded  him  great  rehef  was  no  longer  being  ad- 
ministered, and  he  recognized  the  return  to  the  remedy  after  an 
intermission  of  four  weeks. 

A  very  promising  method  of  treatment  of  ataxia  in  walking  is 
that  devised  by  Dr.  Frankel,  of  Heiden,  Germany,  of  which  Dr.  Starr 
thus  speaks:  "This  method  depends  upon  the  fact  that  the  act  of 
walking,  while  ordinarily  automatic,  may  be  voluntarily  directed. 
In  locomotor  ataxia  the  automatic  mechanism  is  disturbed,  but  an 
effort  of  the  attention  combined  with  a  progressive  training  of  the 
muscles  may  enable  one  to  acquire  a  voluntary  gait,  which  assists  or 
takes  the  place  of  the  automatic  gait.  The  Frankel  movements 
consist  of  attempts  to  follow  a  straight  line,  or  a  curved  fine,  or  a  tri- 
angle upon  the  floor  with  the  tip  of  the  toe;  then,  when  these  motions 
can  be  accurately  performed  by  the  aid  of  sight,  further  motions,  such 
as  taking  a  step  of  a  definite  length,  going  up  stairs,  and  going  through 
various  bodily  exercises,  are  learned.  These  exercises  should  be  gone 
through  with  several  times  a  day,  the  patient  resting  for  five  minutes 
after  every  five  minutes  of  exercise.  While  patients  can  acquire  these 
motions  themselves  after  instruction,  yet  it  is  found  that  they  improve 
much  more  rapidly  if  they  are  personally  instructed  by  the  physician 
every  day.  As  a  result  of  such  continued  instruction  the  gait  may  be 
materially  improved.  I  have  known  patients  who  had  been  unable 
to  walk  for  several  years  to  regain  the  power.  For  details  of  this 
method  the  reader  is  referred  to  Frankel  and  Goldschneider's  books  on 


PARESIS,    OR    GENERAL   PARALYSIS    OF   THE   INSANE  1 33 

the  treatment  of  ataxia.     Well-fitted  boots  with  side  supports  to  the 
ankle  and  rubber  heels  may  assist  the  patient  to  walk." 

This  measure  is  certainly  based  upon  physiologic  principles.  There 
seems  to  be  no  limit  to  the  power  of  training  muscular  coordination, 
whether  it  be  in  the  performance  of  the  most  comphcated  movements 
of  the  fingers  in  playing  on  a  musical  instrument  or  in  the  execution  of 
coordinated  acts  in  mechanics.  We  might  say  that  everything  comes 
by  training  of  the  muscles,  or,  in  other  words,  by  incessant  purposive 
actions  of  the  muscles  made  to  work  together  by  the  will  until  they 
seem  to  be  automatic.  Just  so  a  child  learns  how  to  walk.  To  do  this, 
as  every  one  can  note  in  a  child  when  learning  to  walk,  the  same  per- 
sistent drill  of  the  muscles  must  be  gone  through,  which  calls  for  the 
highest  development  of  muscular  coordination,  for  the  human  child 
is  no  quadruped,  but  has  to  learn  how  to  maintain  his  equihbrium  on 
two  small  feet,  and  at  best  he  has  to  spend  months  ere  he  acquires  this 
power.  The  system  of  Frankel,  therefore,  is  simply  going  back  to  the 
original  lessons  of  childhood,  emphasizing,  however,  the  fact  that  it 
can  be  successful  only  by  constant  repetition. 

PARESIS,  OR  GENERAL  PARALYSIS  OF  THE  INSANE 

It  is  a  noteworthy  fact  that  ordinary  forms  of  insanity,  such  as 
melancholia  and  mania,  are  not  accompanied  by  any  recognizable 
lesions  of  the  brain  itself,  persons  dying  of  these  affections  showing  on 
a  postmortem  examination  what  would  seem  to  be  perfectly  healthy 
brains.  One  great  example,  however,  of  true  structural  changes  in 
the  brain  is  found  in  that  syphiKtic  disease  called  paresis,  or  general 
paralysis  of  the  insane. 

Paresis  is  justly  called  tabes  of  the  brain,  and  not  uncommonly 
it  supervenes  upon  a  chronic  tabes  of  the  spinal  cord.  On  the  other 
hand,  it  may  apparently  develop  independently  of  the  spinal  disease. 
Like  tabes,  it  may  first  show  itself  years  after  the  primary  infection,  and 
sometimes  its  symptoms  may  manifest  themselves  either  very  gradually 
or  suddenly.  Its  prodromata  are  often  manifested  in  changes  about  the 
eyes  and  face.  In  the  eyes  there  may  be  irregularity  in  the  pupils. 
Occasionally  they  may  be  S3anmetrically  contracted,  but  more  com- 
monly one  pupil  is  larger  than  the  other.  Muscular  twitchings  are 
common  in  the  area  supplied  by  the  seventh  nerve,  and  in  speaking 
there  may  be  an  explosive  utterance  due  to  irregular  movements  of  the 
lips.  The  mental  symptoms,  however,  very  soon  dominate  everything 
else.  A  change  in  the  disposition  of  the  patient  is  first  noticeable,  and 
this  often  takes  the  form  of  what  is  called  meglomania  with  delusions 


134  CLINICAL  MEDICINE 

of  grandeur,  the  patients  who  may  be  paupers  regarding  themselves 
as  multimilHonaires,  and  speaking  of  their  great  financial  projects. 
At  other  times  they  break  into  fits  of  uncontrollable  temper  with  their 
relatives,  and  in  such  states  may  commit  crimes  of  violence.  Often 
during  the  course  of  the  mental  disease  the  patients  are  subject  to 
epileptiform  fits,  frequently  ending  in  temporary  comatose  condition. 
Apparent  remissions  may  mark  the  course  of  the  malady,  which,  how- 
ever, is  really  progressive,  involving  not  only  the  mind,  but  developing 
signs  of  irregular  paralyses  of  the  motor  functions,  from  which  the 
patients  finally  take  to  bed.  These  paralytic  symptoms  are  very  irreg- 
ular at  first,  but  gradually  increase,  so  that  ultimately  both  mental 
and  bodily  functions  are  generally  abolished.  The  patients  usually 
die  from  intercurrent  affections,  such  as  pneumonia  or  other  visceral 
derangements. 

The  textural  changes  found  in  the  brain  at  autopsy  consist  of  a 
general  meningitis  involving  both  the  dura  and  the  leptomeninges. 
The  brain  thus  becomes  adherent  to  its  coverings,  if  not  to  the  inter- 
nal tables  of  the  skull.  One  very  constant  feature  is  the  exudation 
of  blood  on  and  in  the  superficial  layers  of  the  cortex,  so  that  it  is 
called  by  some  a  hemorrhagic  meningitis.  Like  tabes,  this  disease  is 
a  great  deal  more  prevalent  among  men  than  among  women.  Many 
causes  to  which  it  has  been  attributed,  such  as  worry,  injuries,  and 
sexual  excess,  can  rank  only  as  predisposing  and  not  as  true  causes  of 
the  complaint,  as  it  is  doubtful  if  any  similar  disease  characterized  by 
such  lesions  ever  occurs  without  syphiHtic  antecedents. 

This  serious  complaint  is  admittedly  incurable,  and  we  should  only 
attempt  to  deal  with  intercurrent  symptoms. 

GONORRHEA 

It  is  doubtful  whether,  when  all  its  complications  and  sequelae 
are  considered,  gonorrhea  may  not  rank  equally  with  s}^hilis  in  the 
mischief  which  it  occasions.  It  is  one  of  the  greatest  mistakes  to  con- 
sider it  as  a  mere  local  disease,  for  though  it  does  begin  with  a  local 
specific  inflammation,  its  causative  agent,  the  gonococcus,  can  spread 
widely  by  infecting  the  blood  and  producing  serious  septicemia,  which 
may  be  quickly  fatal  either  by  production  of  mahgnant  endocarditis 
or  by  infecting  the  circulation.  Osier  mentions  the  case  of  a  young 
man,  "who  within  ten  days  of  the  primary  lesions  was  seized  with 
severe  chill  and  high  fever,  from  which  he  fell  into  a  condition  of 
profound  toxemia,  and  died  early  on  the  morning  of  the  fourth  day  from 
his  first  chill.     At  the  autopsy  there  was  found  only  a  locahzed  acute 


GONORRHEA  135 

urethritis  and  a  small  prostatic  abscess,  the  blood  being  fluid,  tarry- 
black,  and  unlike  anything  I  have  ever  seen  before  or  since." 

Clinical  Course. — In  the  great  majority  of  instances,  however, 
gonorrhea  is  simply  a  localized  specific  urethritis,  but  it  is  a  serious 
mistake  to  confound  it  with  a  urethritis  from  any  other  cause.  How- 
ever local  it  may  be  at  first,  it  is  particularly  obstinate  to  cure  from  the 
tendency  of  the  gonococcus  to  burrow  down  into  the  mucous  crj-pts 
of  the  urethra,  so  that  all  local  measures,  especially  injections,  pass  over 
the  infection.  Gradually  the  gonococcus  proceeds  by  continuity  until 
it  reaches  the  prostatic  portion  of  the  urethra,  from  whence  it  is  very 
difficult  to  dislodge  it.  Acute  inflammation  of  the  whole  organ  may 
then  follow,  accompanied  by  painful  erections,  to  which  condition  the 
name  "chordee"  is  given.  From  infection  of  the  prostate  it  may  pro- 
ceed by  direct  continuity  to  infect  the  testicle. 

When  the  acute  inflammation  subsides,  it  often  leaves  a  chronic 
non-purulent  secretion  called  gleet,  in  which,  however,  vast  numbers 
of  gonococci  remain  present,  and  many  cases  of  infection  of  women 
caused  by  a  chronic  gleet  in  their  husbands  occur  with  the  same  viru- 
lence as  in  the  male,  spreading  to  the  uterus  and  then  to  the  Fallopian 
tubes,  causing  gonorrheal  salpingitis,  and  ultimately  ovaritis.  Thus, 
the  results  of  gonorrheal  infection  may  often  be  the  cause  of  permanent 
sterility. 

One  of  the  most  certain  results,  however,  of  a  chronic  gleet  in  the 
male  is  the  production  of  more  or  less  annular  strictures  of  the  urethra. 
We  have  already  drawn  attention  to  the  fact  that  the  outlet  of  no  tube 
in  the  body  may  be  safely  obstructed.  A  localized  pressure,  for 
example,  on  a  single  bronchus,  narrowing  its  lumen,  is  always  a  serious 
matter,  and,  likewise,  a  man  with  a  localized  stricture  of  the  urethra 
cannot  be  regarded  healthy  because  of  the  widespread  mischief  that 
may  occur  in  any  part  of  the  urinary  tract.  Urethral  strictures,  there- 
fore, are  common  causes  of  cystitis,  and  then  of  troubles  in  the  ureters 
and  pelves  of  the  kidneys. 

It  is  quite  common  for  these  strictures  to  be  multiple,  and  they  all 
have  the  pecuHarity  of  recurring  to  their  original  state  after  attempts 
at  dilatation  have  been  made  by  the  surgeon,  who  begins  with  a  small 
bougie  which  would  just  pass  through  the  stricture,  and  then  uses  larger 
sizes  until  one  equal  to  the  normal  caliber  of  the  urethra  can  be  passed. 
Nevertheless,  this  dilating  process  is  very  unsatisfactory,  for  the  stric- 
tures soon  resume  their  original  state  of  contraction.  Even  when  the 
operation  of  internal  urethrotomy  has  been  performed,  it  is  difficult  to 
prevent  relapses.     Another  feature  of  urethral  strictures  is  that  they 


136  CLINICAL   MEDICINE 

may  become  what  is  called  "irritable."  A  patient  may  have  been  able 
to  pass  water  in  a  fairly  good-sized  stream  until  he  indulges  in  fer- 
mented liquors,  particularly  champagnes,  and  finds  that  shortly  after- 
ward he  is  hardly  able  to  pass  water  at  all.  Similarly,  an  irritable 
stricture  of  the  urethra  becomes  aggravated  by  wetting  the  feet  in 
cold  water.  Patients  generally  learn  to  pass  catheters  or  bougies  for 
themselves,  but  the  risk  of  infecting  the  urinary  passages  by  this 
means  is  very  great,  while  the  introduction  of  the  catheters  or  bougies 
is  nearly  always  painful,  leading  in  one  case  in  my  practice  to  attempt 
urination  with  such  force  that  his  bladder  burst  and  quickly  caused 
his  death. 

Urethral  strictures  may  occur  in  serial  succession  for  years  after  a 
single  impure  sexual  connection.  Like  the  same  question  which  arises 
in  syphiHs,  it  may  be  doubted  whether  a  gonorrheal  infection  is  often 
really  cured,  for  the  gonococcus  will  remain  hidden  for  years  after  it 
has  lodged  in  the  genital  passages,  to  appear  most  unexpectedly  upon 
some  ordinary  excitement. 

Gonorrheal  Rheumatism. — A  not  infrequent  sequel  of  gonorrhea 
is  a  specific  arthritis  unfortunately  called  '  'gonorrheal  rheumatism . "  As 
this  is  dependent  solely  upon  the  gonococcus,  it  has  no  relation  to 
rheumatic  arthritis,  and  it  is  not  at  all  reheved  by  the  saHcylates.  It 
is  usually  polyarthritic,  in  which  the  inflamed  joints  swell  and  are 
very  tender.  The  fever,  however,  is  comparatively  shght.  This 
arthritis  also  differs  in  attacking  joints  which  are  but  rarely  affected 
by  rheumatism,  such  as  the  temporomaxillary  and  sacro-iliac.  The 
effects  of  gonorrheal  arthritis  are  very  variable  in  different  patients. 
One  of  the  most  serious  of  them  is  ankylosis.  Thus  a  case  is  reported 
in  which  every  joint  of  the  body  was  permanently  fixed,  and  the  patient 
had  to  have  some  teeth  extracted  so  that  he  could  be  fed  through  the 
opening.  Some  patients,  however,  experience  only  chronic  pains 
about  the  joints,  which  are  very  obstinate,  though  they  may  not  be  ac- 
companied by  any  signs  of  swelling.  In  other  cases  there  is  much  effu- 
sion, both  in  the  cavity  of  the  joint  itself  and  in  the  surrounding  tissues, 
and  pure  cultures  of  the  gonococcus  have  been  demonstrated  in  these 
fluids.  Frequently  the  joints  attacked  are:  first  the  knee  and  sub- 
sequently the  ankle.  Gonorrheal  arthritis  is  usually  more  obstinate 
than  rheumatic  arthritis,  and  relapses  are  very  common.  The  local 
treatment  of  the  joints  is  the  most  effective,  consisting  of  the  appHca- 
tion  of  the  actual  cautery  by  the  sudden  touch  of  the  tip  of  a  glass 
tube  heated  to  redness  in  the  flame  of  an  alcohol  lamp.  If  a  large 
joint,  such  as  the  knee,  does  not  respond  to  this  measure  the  surgeon 


GONORRHEA 


137 


should  open  the  joint  and  irrigate  it.  In  relapsing  forms  of  arthritis 
a  careful  examination  of  the  discharge  of  the  urethra  may  show  that 
the  source  of  the  joint  trouble  is  in  some  local  development  of  the  gono- 
coccus,  particularly  in  the  prostatic  portion.  An  antigonococcus  serum 
has  been  tried,  with  very  good  results  in  the  hands  of  some,  while  in  the 
hands  of  others  it  has  failed. 

Treatment. — In  the  case  of  the  strictures  marked  benefit  is  occa- 
sionally noticed  after  prolonged  administration  of  iodid  of  potas- 
sium, 60  gr.  a  day,  in  divided  doses  three  times  a  day.  Should 
symptoms  of  iodism  occur,  the  medicine  may  be  suspended  for  a  time 
and  then  resumed.  In  the  treatment  of  the  acute  stage  of  gonorrheal 
urethritis  with  chordee  I  have  found  injections  of  tincture  of  aconite 
in  doses  of  from  10  to  15  drops  in  i  oz.  of  water,  taken  per  rectum,  the 
most  serviceable.  The  rectum  absorbs  the  water  very  quickly,  so 
that  in  ten  minutes  it  is  as  completely  absorbed  as  if  taken  by  the 
mouth,  while  its  local  action  is  much  better  gained  in  this  fashion. 

When  a  patient  comes  into  the  office  having  but  recently  contracted 
gonorrhea  he  should  never  be  encouraged  with  assurance  that  his  case 
can  be  readily  or  speedily  cured.  Every  practitioner  has  his  way  of 
treating  recent  gonorrhea  with  injections  of  various  agents.  I  believe 
that  this  indiscriminate  use  of  fluid  injections  often  tends  rather  to 
transmit  the  disease  further  down  the  urethra,  and  I  think  that,  for 
reasons  already  stated,  whatever  the  nature  of  these  injections,  they  are 
of  Httle  efficacy,  and  I  prefer  to  use  only  such  mild  injections  as  i  gr. 
of  sulphate  of  zinc  to  the  ounce  of  water. 

Should  the  urine  be  highly  acid,  it  becomes  much  less  irritating 
by  making  it  neutral  or  even  alkaline  by  citrate  of  potash  in  20-gr. 
doses  four  times  a  day.  The  fluidextract  of  buchu  also  is  very  ser- 
viceable in  reducing  the  irritation,  and  a  frequent  prescription  of  mine 
is  fluidextract  of  buchu,  12  drams;  liquor  kaH,  6  drams;  syrup  of  orange 
and  syrup  of  ginger,  each  i  oz.;  aqua  menthas,  to  make  a  mixture  of 
8  oz.     Dose,  tablespoonful  in  water  an  hour  after  meals  and  at  night. 


CHAPTER    III 

INFECTIONS    COMMUNICABLE    BY    INTERMEDIATE 

CARRIERS 

/       LOBAR  PNEUMONIA 

It  is  highly  illustrative  of  the  progress  of  our  knowledge  in  recent 
years  that  lobar  pneumonia  is  now  not  regarded  as  a  primary  infection 
of  the  lung.  Instead  of  being  a  lung  disease  it  is  now  considered  a 
local  manifestation  of  a  general  infection  of  the  blood  by  the  pneu- 
mococcus,  which  infection  may  cause  death  without  any  local  mani- 
festation in  the  pulmonary  tissue  or  elsewhere.  Rosenow  has  shown 
that  previous  to  any  development  in  the  lung  the  pneumococcus  may 
be  found  already  circulating  in  the  blood,  and  Hektoen,  Flexner,  and 
other  competent  authorities  have  found  that  the  explanation  of  some 
cases  of  death  occurring  after  a  short  period  of  high  fever  are  due  alto- 
gether to  the  pneumococcus,  occurring  in  vast  numbers  in  the  blood 
without  a  single  local  development  anywhere  in  the  body. 

The  pneumococcus,  in  fact,  is  one  of  the  most  paradoxic  as  well 
as  deadly  causes  of  disease — paradoxic  because  it  is  found  in  the 
mouth  and  saliva  of  the  majority  of  healthy  persons.  How  it  can  act 
as  a  harmless  saprophyte  in  the  mouth  and  then  become  the  com- 
monest cause  of  death,  at  least  in  certain  locations  in  the  United  States, 
such  as  in  Chicago,  where  its  victims  largely  outnumber  the  deaths 
caused  by  tuberculosis,  is  yet  an  unsolved  problem.  Likewise,  it  is 
difficult  to  explain  its  occurrence  in  widely  separated  organs  of  the 
body,  where  the  clinical  course  of  the  disorders  which  it  occasions  are 
each  different  from  one  another,  and  their  identity  would  have  been 
unsuspected  but  for  the  demonstration  of  the  presence  of  this  micro- 
organism. Thus,  it  may  occasion  pleurisy  without  affecting  the  sub- 
jacent lung,  and  similarly  peritonitis  without  inflammation  of  the 
contiguous  viscera,  or  meningitis,  due  solely  to  its  presence — also  of 
both  single  and  multiple  arthritis,  besides  being  a  very  common  cause 
of  otitis  media  in  children. 

In  an  article  which  I  wrote  some  time  ago,  entitled  "The  Vagaries 
of  the  Pneumococcus,"  I  described  a  purely  localized  development  of  the 
pneumococcus  occurring  in  myself,  causing  an  extensive  inflammation 

138 


LOBAR   PNEUMONIA  1 39 

of  the  throat  with  desquamation  of  the  tongue.  These  two  attacks 
happened  at  just  a  year's  interval  between  them,  and  their  causation 
would  have  remained  unknown  but  for  my  finding  an  article  by  an 
eminent  throat  speciaKst  of  England,  Sir  Felix  Simon,  who  pubhshed 
2  cases  of  this  affection,  the  like  of  which  in  his  great  experience  he  had 
never  seen  before,  and  which  proved  to  be  by  the  pneumococcus  from 
an  examination  of  swabs  from  the  throat.  I,  accordingly,  had  my  throat 
secretion  examined,  with  a  report  each  time  of  pure  culture  of  the 
pneumococcus.  In  Simon's  cases  and  in  my  own  the  illness  lasted 
for  more  than  four  weeks  and  was  characterized  by  great  muscular 
debility.  With  my  first  attack  an  unlooked-for  sequel  came  on  five 
weeks  after  the  beginning  of  the  infection,  in  the  shape  of  a  sudden  but 
transient  paralysis  of  the  legs,  from  which  I  soon  recovered  in  every 
respect,  but  a  permanent  weakness  in  walking  followed.  This  paral- 
ysis in  my  case  was  similar  to  the  paralysis  following  diphtheric  exu- 
dations of  the  throat.  In  neither  of  Sir  Felix  Simon's  cases  nor  in  my- 
self was  there  a  single  pulmonary  symptom  throughout  the  whole 
course  of  the  affection. 

The  pneumococcus  was  identified  as  the  cause  of  lobar  pneumonia 
in  1886  by  Frankel.  Previous  to  that  various  other  organisms  asso- 
ciated with  pneumonic  processes  have  been  described,  especially  one 
form  described  by  Friedlander  in  1883,  which  consisted  of  an  oval 
capsulated  coccus  which  he  had  isolated  and  cultivated  from  cases  of 
lobar  pneumonia. 

The  pneumococcus  is  both  aerobic  and  anaerobic,  according  to 
circumstances.  In  appearance  it  is  a  diplococcus.  It  occurs  in  the 
body-fluids  in  pairs,  of  which  the  individual  members  are  lanceolate 
or  candle-flame  shaped,  with  the  rounded  bases  in  apposition.  Culti- 
vated on  some  media  it  assumes  the  formation  of  a  streptococcus. 

Clinical  Course. — As  might  be  expected  in  a  general  infection  of 
the  blood  preceding  local  involvement  of  the  lung,  many  cases  show  well- 
marked  prodromata,  such  as  headache,  wandering  pains  or  disturbances 
in  the  aHmentary  canal,  as  well  as  the  respiratory  tract.  The  nasal 
pharyngeal  or  bronchial  catarrh  not  infrequently  precede  the  definite 
onset  of  lobar  pneumonia.  In  80  per  cent. ,  however,  the  onset  is  sudden, 
when  the  course  of  the  disease  is  presaged  by  severe  rigor  pain  in  the 
side,  rapidly  rising  temperature,  and  characteristic  pneumonic  breath- 
ing. These  cases  usually  present  a  definite  crisis,  and  are  relatively  of 
short  duration,  the  pulse  being  full  and  strong.  On  the  other  hand,  the 
symptoms  may  be  of  a  gradual  onset,  generally  indicating  a  prolonged 
course  with  a  termination  by  lysis  instead  of  by  crisis,  and  are  more 


I40  CLINICAL  MEDICINE 

likely  to  be  attended  by  unfavorable  complications.  At  this  early 
stage  some  patients  show  a  serious  apprehension  of  the  outcome  of 
the  disease,  a  symptom  of  unfavorable  import. 

During  the  onset  the  dyspnea  is  altogether  out  of  proportion  to 
the  amount  of  lung  iavolvement,  and,  if  early  accompanied  by  cyano- 
sis, has  an  unfavorable  significance  from  its  indicating  serious  infection 
of  the  blood.  This  leads  us  at  this  juncture  to  refer  to  the  great  differ- 
ence in  that  important  element  which  is  termed  "virulence,"  for  this 
element  varies  greatly  in  different  epidemics,  and  a  cyanosis  which 
cannot  be  ascribed  to  the  extent  of  the  pulmonary  lesion  indicates  a 
process  of  severe  general  poisoning.  The  rigors  on  that  account  vary, 
being  sometimes  short  and  at  other  times  prolonged.  Although  the 
patient  feels  very  cold  during  the  rigor,  the  thermometer  is  already 
at  a  very  high  grade,  and  does  not  rise  upon  the  subsequent  develop- 
ment of  the  fever.  One  symptom  is  of  great  importance,  and  that  is 
burning  heat  of  the  skin,  sensible  when  the  hand  is  laid  upon  the  body. 
In  no  other  disease  is  this  symptom  so  marked,  except  in  developing 
erysipelas. 

An  old  saying  in  medicine  is  that  pneumonia  affert  plus  periculi 
quam  dolores  (more  of  peril  than  of  pain),  a  statement  which  is  quite 
true  of  those  pneumonias  which  complicate  other  diseases,  such  as 
typhoid  fever  and  Bright's  disease,  when  the  presence  of  pneumonia 
may  not  even  be  suspected  until  it  is  revealed  at  autopsy ,  but  in  typical 
lobar  pneumonia,  with  a  rigor  and  rapidly  rising  temperature,  pain  is 
one  of  the  leading  symptoms.  It  is  then  due  to  concomitant  pleurisy, 
which  further  aggravates  the  dyspnea  by  limiting  the  movements  of 
the  chest. 

Cough. — Every  form  of  acute  pleurisy  causes  persistent  cough  until 
the  surfaces  of  the  inflamed  pleura  are  separated  by  an  effusion  of  serum. 
At  the  onset  of  pneumonia  the  pleurisy  is  dry,  the  pain  may  be  very 
severe,  and  of  a  stabbing  character.  As  at  this  stage  the  secretion  of 
the  bronchi  is  scanty  and  viscid,  the  cough  is  short,  hacking,  and  husky 
in  its  sound.  Other  symptoms  often  accompany  the  onset,  one  of 
which  is  vomiting,  very  often  a  first  sign  in  children.  It  may  be  well  to 
remark  that  the  sudden  onset  of  vomiting  with  fever  in  children  is 
frequently  due  either  to  the  development  of  scarlet  fever  or  of  pneu- 
monia; in  children  also  the  first  symptom  may  be  a  convulsion.  It  is 
not  infrequent  for  severe  pain  in  the  region  of  the  appendix  to  occur 
with  the  onset  of  pneumonia,  especially  of  the  right  lung,  and  a 
number  of  instaaces  have  been  reported  where  these  patients  have 
been  subjected  to  the  operation  for  appendicitis  without  reveahng 


LOBAR   PNEUMONIA  141 

anything  wrong  there.  Therefore,  in  every  case  of  pain  so  locaHzed, 
a  careful  examination  of  the  lungs  should  be  made. 

We  may  mention  of  the  respiratory  symptoms  the  play  of  the  nostrils, 
and  often  a  nostril  of  the  affected  side  is  more  dilated  than  its  fellow. 
The  discoloration  of  the  face  consists  of  a  bright  flush,  particularly  pro- 
nounced on  the  malar  processes,  and  not  uncommonly  more  on  the 
affected  side.  The  breathing  of  lobar  pneumonia  may  be  of  much 
diagnostic  significance  when  compared  to  the  pulse.  The  expirator}^ 
grunt  is  a  sign  of  great  diagnostic  importance,  especially  in  children. 
It  may  occur,  although  pain  may  be  absent.  A  special  change  in  the 
ratio  of  the  pulse  to  the  breathing  is  one  of  the  most  practical  clinical 
signs  of  pneumonia,  the  normal  ratio  of  the  respiration  to  the  pulse 
being  i  :  4.5,  but  in  pneumonia  it  may  be  i  :  3,  1:2,  or  even  i  :  i. 
As  elements  in  the  prognosis,  the  frequency  both  of  the  pulse  and  res- 
piration is  important.  In  adults  a  pulse  that  does  not  rise  above  1 20 
is  not  of  much  significance,  but  the  prognosis  becomes  worse  with 
every  rise  of  5  beats  above  that,  hkewise  the  respirations.  At  the 
beginning,  when  there  is  much  pleuritic  pain,  the  breathing  may  be 
quite  hurried  on  account  of  the  pain  alone,  but  afterward,  when  the 
ratio  characteristic  of  pneumonia  between  the  pulse  and  the  breath- 
ing has  been  estabhshed,  the  more  frequent  the  breathing,  the  worse  the 
outlook.  A  steady  decKne  in  the  force  of  the  pulse  must  be  expected 
after  the  second  day,  but  if  a  crisis  has  occurred  and  the  pulse  remains 
very  weak  this  sign  is  unfavorable. 

The  onset  of  delirium  in  pneumonia  is  very  common,  but  of  varying 
significance.  It  is  of  great  import  if  it  occurs  in  alcohoHcs  with  the 
characteristics  of  deUrium  tremens.  In  others  it  usually  bears  some 
relation  to  the  temperature,  and  in  all  cases  calls  for  extreme  watchful- 
ness of  the  patients,  because  they  may  become  suddenly  maniacal,  and 
endeavor  to  get  out  of  bed,  to  throw  themselves  out  of  the  window,  or  to 
attack  their  attendants.  In  senile  and  asthenic  cases  the  deHrium  is 
generally  of  a  moderate  variety. 

Insomnia  is  very  common,  and  may  be  ascribed  chiefly  to  rapid 
breathing  attendant  upon  the  disease.  It  should  never  be  treated  with 
full  doses  of  opiates,  because  opiates  work  badly  in  all  forms  of  pneu- 
monia. DeHrium  is  said  to  be  more  common  when  the  apices  are  in- 
volved. 

It  has  long  been  recognized  that  the  expectoration  of  lobar  pneu- 
monia is  characteristic,  and  has  been  described  as  rusty.  This  kind 
of  expectoration  may  set  in  very  early  on  the  first  day,  but  usually  not 
until  the  second  or  third  day.     Its  color  is  due  to  the  admixture  of 


142  CLINICAL   MEDICINE 

blood,  and  is  viscid  at  the  beginning  and  becomes  more  abundant 
toward  the  close  by  a  mixture  of  purulent  bronchial  secretion.  Occa- 
sionally, especially  in  apex  pneumonia,  the  expectoration  may  be  so 
bloody  as  to  suggest  the  hemoptysis  accompanying  phthisis. 

A  notable  feature  of  croupous  pneumonia  is  its  termination  by  crisis, 
in  which  the  fever  rapidly  dechnes  to  normal  or  to  below  normal. 
Theories  to  account  for  crises  are  numerous.  The  causes  of  this 
phenomena,  therefore,  must  be  regarded  as  very  obscure,  the  most 
probable  of  them  being  that  great  quantities  of  antitoxin  are  formed 
which  arrest  the  pneumonic  process.  As  a  rule,  the  earher  the  crisis  the 
better.  It  may  occur  any  day  between  the  fifth  and  the  tenth.  The 
fall  in  the  temperature  may  be  between  5°  and  8°  in  twenty-four  hours; 
at  other  times  it  takes  more  commonly  from  thirty-six  to  forty-eight 
hours  to  become  complete.  Other  phenomena  often  attend  it,  such  as 
profuse  sweating  or  the  occurrence  of  diarrhea.  In  persons  who  are 
very  much  reduced,  a  crisis  is  followed  by  a  more  or  less  prolonged 
condition  of  general  prostration  and  dehrium  which  may  have  preceded 
the  crisis.  This  may  continue  in  a  low  form  for  some  days  afterward, 
accompanied  in  some  cases  by  marked  bradycardia. 

The  anatomic  changes  accompanying  pneumonia  may  be  divided 
into  four  stages:  First,  that  of  simple  hyperemia;  this  is  soon  fol- 
lowed by  engorgement,  usually  called  the  stage  of  red  hepatization,  and 
is  caused  by  an  extreme  fibrinous  exudation  into  the  air- vesicles  and 
the  minute  bronchi.  The  lung  tissue  in  this  stage  becomes  solid  and 
heavy,  and  pieces  of  it  sink  in  water.  There  is  no  frothy  exudation 
apparent  on  the  cut  surfaces.  When  a  lung  is  extensively  consolidated, 
it  becomes  so  swollen  that  the  marks  of  the  ribs  appear  upon  it  and  the 
affected  lung  greatly  increases  in  weight.  A  fourth  stage  is  called 
gray  hepatization,  due  to  changes  in  the  exudate,  which  now  becomes 
largely  infiltrated  by  leukocytes.  It  is  remarkable  how  extensive  these 
changes  may  become  without  affecting  the  structure  of  the  air- vesicles 
themselves,  for  the  whole  exudation  may  be  reabsorbed  into  the  circu- 
lation, leaving  the  air-vesicles  intact,  and  thus  differing  markedly 
from  the  changes  in  bronchopneumonia,  in  which,  as  will  be  subse- 
quently described,  both  the  walls  of  the  vesicles  and  the  interstitial 
tissues  may  become  disorganized. 

Auscultation. — Though  it  is  not  proposed  in  this  work  to  treat 
fully  the  subject  of  auscultation,  yet  in  pneumonia  some  remarks  are 
advisable.  The  first  change  in  pneumonia  is  an  increase  in  the  loud- 
ness of  the  breathing  resembling  that  which  is  normal  in  children,  and 
is,  therefore,  called  peurile  respiration.     This  is  quickly  succeeded  by 


LOBAR   PNEUMONIA  1 43 

absence  of  vesicular  breathing  and  its  substitution  by  an  adventiti(jus 
sound  called  the  pneumonic  crackle,  which  occurs  only  in  inspiration, 
and  cannot  be  coughed  away  as  a  similar  sound  can  occurring  in  acute 
bronchitis.  Another  sign  at  this  stage  is  that  the  expiration  is  clear 
and  raised  in  pitch.  Succeeding  this  is  bronchial  breathing,  which  is 
tubular  in  character,  usually  most  pronounced  in  inspiration,  but  in 
extensive  consolidation  may  be  present  in  both  acts  of  the  breathing. 
In  bronchial  breathing  there  is  a  distinct  interval  between  the  end  of 
inspiration  and  the  beginning  of  expiration.  Along  with  these  changes 
an  increase  of  vocal  fremitus  perceptible  to  the  touch  is  a  characteristic 
sign,  and  when  the  process  affects  the  surface  there  is  dulness  on  per- 
cussion, but  in  centric  pneumonia,  or  pneumonia  deep  under  the  sur- 
face, these  sounds  may  be  scarcely  appreciable. 

There  are  many  clinical  resemblances  between  lobar  pneumonia 
and  erysipelas.  Like  erysipelas,  lobar  pneumonia  begins  at  a  definite 
focus  and  then  spreads  by  contiguity,  but  in  some,  though  not  common 
cases,  pneumonia  appears  in  one  place  and  then  disappears  from  that 
to  appear  in  another,  and,  like  erysipelas,  it  is  apt  in  succeeding  years 
to  occur  with  the  same  characters.  Other  forms  of  asthenic  pneumonia 
occur  in  old  people,  so  as  to  lead  to  the  term  "senile  pneumonia"  by  some 
authors.  Senile  pneumonia  is  a  very  fatal  form  of  the  disease  occurring 
in  old  people.  It  is  often  obscure  in  its  symptoms,  not  accompanied 
by  pronounced  cough  or  expectoration,  and  often  by  a  low  grade  of 
fever,  its  chief  characters  being  systemic  prostration  with  great  feeble- 
ness of  the  pulse.  These  cases  are  sometimes  complicated  by  abscess 
or  by  gangrene.  The  physical  signs  may  be  Hmited  to  dulness  on 
percussion  and  to  suppression  of  breath  sounds.  Due  to  these  features 
the  presence  of  pneumonia  maybe  expected  in  all  persons  who,  having 
fever,  show  marked  change  in  their  physical  strength.  Though  all 
of  these  symptoms  may  accompany  cough  and  bronchial  secretion, 
and  therefore  lead  to  the  diagnosis  of  bronchopneumonia,  it  is  strik- 
ing to  find  that  in  many  of  them  the  only  organism  present  is  Frankel's 
pneumococcus.  We  should  say,  however,  that,  as  in  other  infectious 
diseases,  the  rule  is  to  find  mixed  infections  with  streptococci,  staphylo- 
cocci, and  other  organisms  present  in  the  terminal  stages  of  Hfe. 

The  Heart. — The  pneumococcus  when  it  causes  pneumonia  also 
causes  much  trouble  with  the  heart.  Of  all  the  signs  given  by  the 
pulse,  the  most  ominous  is  a  change  in  rhythm,  whether  it  occurs  early 
or  late.  I  fully  agree  with  Dr.  Mackenzie  that  a  change  in  this  respect, 
that  is,  virtually  an  irregular  pulse,  presages  death  more  than  any  one 
symptom.     While  the  toxin  of  pneumonia  produces  parenchymatous 


144  CLINICAL  MEDICINE 

changes  in  the  heart  walls,  these  are  not  different  from  like  changes  in 
the  cells  of  the  kidneys  and  of  the  Hver,  but  in  pneumonia  the  difference 
in  the  behavior  of  the  two  ventricles  of  the  heart  is  well  marked.  The 
left  ventricle  pumps  its  blood  into  the  systemic  arteries  easier  than  it 
does  in  health,  because  the  arteries  are  everywhere  dilated.  But  the 
conditions  confronting  the  right  ventricle  are  wholly  different.  Besides 
its  walls  being  thinner  and  weaker  than  those  of  the  left  ventricle,  the 
obstacle  of  a  hepatized  lung  throws  increased  labor  upon  the  right 
ventricle,  so  that  it  may  fatally  terminate  its  function. 

Moreover,  the  pneumococcus  is  prone  to  attack  the  pericardium. 
The  occurrence  of  pericarditis,  however,  varies  in  different  epidemics, 
some  authors  putting  it  at  12  per  cent,  in  all  cases  of  pneumonia  and 
others  at  50  per  cent.  This  pericarditis  is  often  difficult  to  detect 
from  the  concomitant  presence  of  pulmonary  rales  and  pleural  friction 
sounds,  so  that  its  presence  may  be  revealed  only  at  autopsy.  The 
seriousness  of  this  complication  depends  upon  the  nature  of  the  exu- 
date, the  least  serious  being  when  it  is  plastic,  rather  than  serofibrinous, 
when  the  danger  comes  from  its  amount.  The  worst  condition  is  when 
it  is  purulent,  for  then  nothing  but  a  surgical  evacuation  will  avail. 

Both  acute  and  chronic  endocarditis  can  be  caused  by  the  pneu- 
mococcus, and  with  many  it  is  a  fatal  compHcation.  The  acute  form 
is  more  common  in  patients  above  thirty  than  at  an  earher  age.  The 
aortic  and  pulmonary  valves  are  oftener  attacked  than  the  mitral 
and  tricuspid.  Such  endocarditis  may  be  overlooked  on  account  of 
the  uncertainty  of  its  signs  among  those  due  to  pulmonary  or  pericar- 
dial conditions.  If,  after  a  time,  the  chnical  picture  is  that  of  a  con- 
tinuous fever  or,  worse  yet,  if  the  fever  be  intermittent  and  accom- 
panied by  chills,  then  ultimate  death  is  well-nigh  certain. 

Treatment. — As  to  the  treatment  of  pneumonia,  one  great  indica- 
tion is  to  supply  the  patient  with  all  the  fresh  air  possible.  Whether 
the  good  effects  here  are  due  to  the  unfavorable  action  of  oxygen  on 
the  growth  of  the  pneumococcus  itself,  or  to  the  property  of  oxygen 
to  strengthen  muscular  function  is  uncertain,  but  certain  it  is  that 
the  chances  of  a  pneumonia  patient  are  better  if  his  couch  be  put  in  a 
tent  on  the  hospital  roof  than  down  in  its  wards. 

Another  indication  is  to  avoid  so  far  as  possible  all  bodily  move- 
ment. No  acute  case  of  the  disease  should  be  moved  into  a  hospital 
over  the  rough  pavement,  for  this  is  very  often  fatal.  I  do  not  allow 
a  pneumonia  patient  to  sit  up  for  examination.  I  have  often  seen  the 
Hps  become  blue  on  merely  turning  the  body  from  side  to  side,  and 
when  this  has  to  be  done,  it  should  be  as  gently  as  possible.     This 


LOBAR   PNEUMONIA  145 

shows  how  critical  the  condition  of  pneumonia  patients  must  be,  simply 
owing  to  heart  weakness.  The  best  stimulant  for  heart  failure  is  cam- 
phor given  hypodermically  in  ^-gram  or  7|-gr.  doses  dissolved  in 
a  syringeful  of  sterilized  almond  or  oHve  oil,  and  which  can  be  repeated 
in  two  hours  if  necessary.  Strychnin  is  much  inferior  to  camphor  for 
this  purpose.  One  authority  recommends  camphor  hypodermically  in 
doses  two  or  three  times  greater  than  that  above  recommended  as 
a  specific  in  pneumonia. 

In  many  cases  the  onset  of  pneumonia  is  accompanied  by  such 
severe  pleuritic  pain  that  the  breathing  becomes  very  hurried,  short, 
and  shallow,  and  for  a  time  the  aspect  of  the  patient  is  that  of  a  serious 
shock.  At  this  juncture,  but  at  no  other  time,  a  single  dose  of  |  or  ^ 
gr.  of  morphin  given  hypodermically  over  the  seat  of  the  pain  is  of 
great  service. 

A  different  condition  sometimes  occurs  at  this  early  stage  which 
is  not  now  treated  as  successfully  as  it  was  in  the  days  of  our  forefathers. 
That  condition  is  one  of  rapid  congestion  of  the  affected  lung,  causing 
acute  dilatation  of  the  right  ventricle  with  suffocative  dyspnea.  Be- 
cause this  state  is  promptly  reHeved  by  venesection,  much  more  so 
than  by  leeches  or  by  cupping,  our  predecessors  were  led  to  free 
bleeding  in  pneumonia  as  a  routine  practice  through  the  whole  course 
of  the  complaint.  This  was  a  serious  error,  but  the  fact  remains 
that  nothing  so  soothes  the  patient  and  improves  the  subsequent  con- 
ditions as  a  single  venesection  when  the  signs  above  given  indicate  it. 

After  an  experience  of  half  a  century  in  the  treatment  of  pneumonia 
and  after  trying  a  great  variety  of  remedies,  I  came  in  time  to  the 
belief  that  it  did  not  make  much  difference  what  we  use  or  what  we 
do  not  use.  Patients  recovered  or  died  just  the  same  as  they  did 
one  hundred  years  ago.  But  during  the  past  fifteen  years  I  have 
seen  reason  to  change  my  mind.  Both  in  hospital  and  consultatioQ 
practice,  including  two  severe  epidemics  of  pneumonia,  I  have  had  a 
greater  percentage  of  recoveries  than  before,  owing,  as  I  suppose,  to 
the  use  of  one  drug,  which  among  other  effects  changes  the  course  of 
the  fever,  so  that  in  70  per  cent,  it  ends  by  lysis  instead  of  by  crisis. 
That  drug  is  creosote  carbonate  in  15-gr.  doses  given  every  two  or 
three  hours  in  a  specially  prepared  emulsion,  which  is  so  well  borne 
by  the  stomach  that  I  have  known  it  to  stay  down  when  everything 
else  was  rejected.  The  extreme  susceptibility  of  the  pneumococcus 
to  the  faintest  trace  of  carbolic  acid  may  allow  of  this  preparation  be- 
ing regarded  as  a  true  blood  germicide.  I  have  seen  no  injurious  effect 
produced  by  it  even  when  its  absorption  causes  the  urine  to  become  dark. 
10 


146  CLINICAL  MEDICINE 

Surgeon-general  Stokes  of  the  United  States  Navy  informs  me 
that  when  he  heard  of  my  recommendation  of  creosote  carbonate  for 
pneumonia  being  given  ten  years  ago  at  the  New  York  Academy  of 
Medicine  he  directed  that  this  dosing  of  creosote  carbonate  should  be 
used  in  all  the  ships  of  the  United  States  Navy  to  pneumonia  patients, 
in  all  parts  of  the  world,  on  account  of  the  favorable  reports  which  he 
received  of  the  results  of  this  treatment  compared  with  those  of  former 
years. 

The  prescription  for  this  emulsion  is  as  follows: 

I^.     Gum  acacia oiv; 

Aquae 5  ivss; 

F.  mucil. 

Creosotal ad.  Sv-TTgxx; 

M.  ft.     Emulsio  et  adde: 

Aquse  menthae 5  iv; 

Glycerini o j; 

Aquae ad.  oviij. 

Dose. — One  tablespoonful,  equal  to  15  gr. 

Sometimes,  after  the  crises  the  general  condition  of  the  patient  con- 
tinues unfavorable,  marked  by  muttering  dehrium  and  by  feeble  pulse. 
This  calls  for  special  stimulants  of  the  heart,  of  which  the  best  is  by 
keeping  up  the  hypodermics  of  camphor  every  four  hours  along  with  a 
pill  of  I  gr.  of  powdered  squills,  ^  gr.  of  sulphate  of  spartein,  and  2  gr. 
of  caffein  citrate.  Occasionally,  15  drops  of  the  tincture  of  nux  vom- 
ica with  a  dram  of  the  aromatic  spirits  of  ammonia  may  be  taken  one- 
half  hour  after  the  hypodermics  of  camphor  in  sterilized  almond  oil. 

TYPHOID  FEVER 

Of  the  acute,  indirectly  communicable  diseases  typhoid  fever 
easily  takes  the  lead,  for  it  prevails  the  world  over,  in  all  seasons  and 
in  all  cHmates.  It  is  also  an  exclusively  human  disease,  and,  as  we 
now  know,  though  not  contagious,  its  origin  in  every  case  is  from  some 
person,  though  he  may  be  miles  away. 

Though  probably  of  great  antiquity,  its  identification  as  a  distinct 
disease  was  late  in  history,  owing  to  its  confusion  with  other  infectious 
fevers.  In  England,  though  typhoid  fever  was  clearly  described  by 
WilHs  in  1643,  it  was  generally  regarded  as  a  form  of  typhus  fever 
down  to  the  time  of  the  younger  Jenner  in  1858.  In  France,  on  the 
other  hand,  it  was  plainly  recognized,  and  its  special  lesions  in  the 
intestine  carefully  described,  especially  by  Louis  in  1829,  but  even 
he  supposed  that  the  continued  fevers  in  other  parts  of  Europe,  which 
were  undoubtedly  typhus,  were  all  one  disease,  and  he,  therefore,  pro- 


TYPHOID    FEVER  I47 

posed  the  name  typhoid,  or  like  typhus,  for  the  complaint,  a  name 
which  unfortunately  it  still  retains.  In  England  it  is  now  frequently 
termed  "enteric  fever,"  but  the  objection  to  this  term  is,  like  all  medical 
terms,  based  upon  symptoms;  it  overlooks  the  fact  that  t>q)hoid  fever 
is  a  systemic  blood  disease,  and  hence  may  occur  with  very  few,  or 
even  without  intestinal  lesions.  The  reason  why  France  took  the 
lead  in  this  respect  was  because  typhoid  was  the  prevaiHng  fever  in 
that  country,  while  typhus  was  rare.  In  England,  on  the  other  hand, 
both  these  fevers  coexisted.  It  was  really  in  America  that  the  differ- 
ence was  first  established,  particularly  by  Gerhardt,  who,  having 
studied  under  Louis,  recognized  typhoid  in  Philadelphia  in  1835,  and 
then  followed  an  epidemic  of  typhus  in  the  same  city  in  1836,  so  that  he 
was  the  first  to  meet  these  two  distinct  fevers,  face  to  face,  and  to  dis- 
criminate them  accordingly.  He  was  soon  followed  by  other  American 
physicians,  such  as  G.  C.  Shattuck,  of  Boston,  while  in  1842  Elisha 
Bartlett  pubHshed  the  first  treatise,  in  which  the  two  diseases  were 
discussed  separately  and  distinguished  from  each  other.  The  old 
confusion,  however,  died  hard,  for  after  I  left  the  New  York  Quarantine, 
in  1 86 1,  I  found  myself  almost  alone  at  a  meeting  of  the  New  York 
County  Medical  Society  in  maintaining  that  typhoid  fever  was  not 
"abdominal  t}^hus."  In  medicine,  as  in  other  things,  it  is  easy  to  be 
wise  after  the  events  and  wonder  why  people  were  not  so  before. 

Etiology. — Typhoid  fever  is  altogether  due  to  its  own  bacillus,  dis- 
covered by  Eberth  in  1880.  It  is  an  actively  motileand  flagellated  or- 
ganism I  to  3  mm.  in  length  and  5  to  8  mm.  in  diameter.  It  does  not 
form  spores.  It  is  non-Hquefying,  growing  best  at  33°  C.  Its  toxin, 
already  mentioned,  belongs  to  the  intracellular  group.  This  organ- 
ism is  killed  by  a  temperature  of  60°  C.,  but  cannot  be  killed  by  cold, 
even  that  of  liquid  air,  and  both  freezing  and  thawing  does  not  kill  it. 
The  agent  of  typhoid  fever,  like  that  of  Asiatic  cholera,  must  be 
swallowed  to  produce  its  effects,  although  it  is  claimed  that  the  baciUi 
may  be  carried  about  by  dust,  yet  they  are  not  inhaled  so  as  to  infect 
the  lungs,  but  pass  from  the  mouth  to  the  alimentary  canal.  The 
modes  of  its  dissemination  are  so  various  that  it  is  doubtful  if  any 
other  communicable  agent  has  so  many  ways  for  producing  its  infec- 
tion. First  in  importance  we  would  rate  its  distribution  in  drinking- 
water.  These  bacilH  can  five  in  distilled  water  for  three  months,  but 
in  water  heavily  charged  with  organic  material  they  cannot  five  long, 
because  they  are  attacked  by  other  bacteria.  The  discharges  from  a 
single  patient,  sick  with  typhoid  fever,  contain  so  many  milKons  of 
these  bacteria  that  they  may  suffice  to  start  an  epidemic  in  a  town 


148  CLINICAL  MEDICINE 

miles  away  from  their  original  source,  as  is  illustrated  in  the  epidemic 
in  Plymouth,  Pa.,  in  1885.  This  town  of  8000  inhabitants  had  its 
water  supply  derived  largely  from  a  stream  on  the  watershed  of  which 
there  were  only  two  houses.  It  was  found  that  in  one  of  these  houses 
on  the  stream  there  had  been  one  patient  ill  with  typhoid  fever.  At 
first  the  discharges  from  this  patient  were  thrown  on  the  snow  and 
frozen  ground,  until  the  thaw  came  which  washed  the  material  on 
the  surface  into  the  stream.  Soon  after  typhoid  fever  appeared  in 
the  town,  and  in  a  few  days  there  were  from  50  to  100  new  cases  a 
day;  the  total  number  in  this  town  of  8000  amounting  to  1104. 
Other  instances  of  water-borne  typhoid,  both  in  small  towns  and  large 
cities,  might  be  multiphed  indefinitely,  as  these  bacilh  are  not  affected 
by  cold;  so  also  they  may  become  the  means  of  infecting  a  town  by 
receiving  discharges  on  the  ground  during  the  winter  months. 

Next  to  water  come  articles  of  food,  chief  of  which  is  milk.  Milk 
is  an  excellent  medium  for  the  propagation  of  every  kind  of  infection, 
because  it  is  so  well  adapted  for  the  culture  of  various  forms  of  patho- 
genic bacteria.  Milk  infection,  therefore,  may  account  for  the  greater 
prevalence  of  t3qDhoid  fever  in  isolated  rural  districts  than  in  the  case 
of  large  cities.  For  the  same  reason,  ice-cream  may  be  the  source  of 
infection.  Shell-fish  are  by  no  means  an  uncommon  cause  of  outbreaks 
of  typhoid  fever,  because  the  presence  in  them  of  typhoid  bacilli 
has  frequently  been  demonstrated.  In  one  year  I  was  called  in  consul- 
tation to  5  cases  of  this  fever  in  a  fashionable  hotel  in  New  York  and 
to  7  cases  in  an  adjoining  hotel,  and  then  to  1 2  cases  in  another  well- 
known  hotel,  and,  on  examination,  in  every  instance,  I  found  that  the 
persons  affected  were  accustomed  to  have  their  first  course  that  of  raw 
oysters.  Meanwhile,  typhoid  fever  was  not  prevailing  extensively  in 
the  houses  among  the  better  classes  in  the  neighborhood,  except  in 
one  instance,  where  I  found  a  young  boy  and  his  nurse  both  down 
with  typhoid  fever,  while  the  other  members  of  the  family  escaped, 
the  explanation  being  that  only  he  and  his  nurse  partook  of  raw 
oysters  every  day.  In  all  these  cases  the  oysters  came  from  beds  on 
Long  Island  Sound,  which  were  infected  by  the  sewage  from  the  shore 
towns.  On  the  other  hand,  oysters  from  the  beds  along  the  shores 
of  Cape  Cod,  where  there  was  no  chance  for  such  infection,  were  never 
the  cause  of  typhoid  fever,  as  was  demonstrated  by  the  New  York 
Board  of  Health.  Vegetables  can  be  carriers  of  this  infection  only 
when  eaten  in  an  uncooked  state,  the  vegetables  having  been  grown  on 
land  which  has  been  fertilized  by  infected  material.  Again,  nothing 
can  be  more  clearly  demonstrated  than  that  flies  are  very  effective 


TYPHOID    FEVER  1 49 

agents  for  carrying  this  infection  about  their  feet  and  then  depositing 
it  on  every  variety  of  food.  Both  in  the  Spanish-American  War  in 
America  and  in  the  South  African  Boer  campaign,  where  there  were 
great  swarms  of  flies  in  the  camps,  examination  showed  that  these  in- 
sects were  extremely  effective  agents  in  spreading  the  disease.  Where 
the  discharges  of  the  patient  contaminate  clothing  such  articles  may 
become  dangerous,  as  is  proved  by  the  liability  of  laundresses  who 
become  infected.  In  my  wards,  in  Roosevelt  Hospital,  I  never  allowed 
more  than  a  certain  number  of  typhoid  patients  to  be  admitted  into  a 
ward,  because  of  the  liability  of  the  nurses,  who  were  attendant,  to 
contract  this  fever  when  they  had  too  much  to  do  in  their  duty.  Such 
cases  do  not  prove  direct  infection,  but  only  that  infection  may  occur 
where  the  conditions  of  crowding  of  the  patients  allow  of  the  dis- 
charges remaining  on  the  articles  of  clothing  or  bedding. 

It  is  now  clearly  demonstrated  that  typhoid  fever  produces  a  true 
infection  of  the  blood.  This  infection  begins  early,  the  highest  per- 
centage occurring  in  the  first  week,  less  in  the  second  week,  still  less 
in  the  third  week,  and  less  again  in  the  fourth  week.  In  relapses  the 
bacilli  reappear  in  nearly  every  case.  They  are  present  in  the  rose- 
spots  of  the  skin  and  in  every  gland.  They  have  even  been  found  in  the 
brain,  the  spinal  cord,  and  the  meninges.  In  the  lung  they  are  usually 
accompanied  by  other  organisms,  also  in  the  Hver  and  spleen.  The 
most  important  organs,  however,  for  retaining  the  typhoid  bacillus 
are  the  gall-bladder  and  the  kidneys.  In  the  gall-bladder  the  bacilli 
may  remain  living  for  years,  and  are  not  uncommonly  the  cause  of  the 
concretions  which  grow  into  gall-stones.  It  is  difi&cult  to  account  for 
their  persistence,  often  in  enormous  numbers,  in  the  urine  for  months, 
if  not  years  after  the  patient  has  recovered  from  typhoid  fever.  These 
persons  are  called  typhoid  carriers,  and  may  be  the  reason  of  un- 
expected outbreaks  of  this  fever,  which  cannot  otherwise  be  accounted 
for;  which  fact  proves  that  the  Bacillus  typhosus  may  lurk  every- 
where where  there  are  persons,  and  explains  the  universal  prevalence 
of  this  disease  where  human  beings  come  together. 

Clinical  Course. — The  onset  is  rarely  abrupt ;  the  period  of  incuba- 
tion is  from  eight  to  fourteen  days  or  even  more,  quite  commonly 
three  weeks^onset  is  characterized  often  by  a  feeling  of  lassitude 
both  bodily  and  mentally.  Occasionally  it  sets  in  with  chiUs,  but  the 
most  common  symptom  is  headache,  which  is  continuous  and  often 
very  severe,  usually  frontal,  but  sometimes  occipital.  The  best 
remedy  for  this  headache  is  phenacetin,  15  gr.,  with  2  gr.  of  caffein 
citrate.     Not  uncommonly  there  is  some  diarrhea  at  the  onset,  but 


I50 


CLINICAL  MEDICINE 


less  frequently  constipation  instead.  Vague  pains  in  the  abdomen 
are  quite  common.  A  persistent  headache,  with  rise  of  temperature, 
is  always  a  symptom  indicative  of  infection.  The  fever  in  the  great 
majority  of  cases  advances  slowly  in  the  first  week,  falling  in  the  mora- 
ing  and  rising  in  the  evening,  perhaps  gaining  one  degree  in  the  morn- 
ing every  day  until  by  the  end  of  the  week  the  morning  temperature 
ranges  from  102°  to  104°  F.  The  pulse  at  the  beginning  of  the  typhoid 
is  often  characteristic  in  being  slow,  relatively  to  the  temperature. 
I  have  often  strongly  suspected  typhoid  when  the  frequency  of  the 
pulse  in  the  first  week  was  not  much  above  normal,  while  the  temper- 
ature was  nearly  104°  F.,  for  no  other  febrile  disease  is  apt  to  show  such 
discrepancy.  About  this  time  the  rash  appears.  In  typhoid  the 
pulse,  even  in  the  first  week,  is  often  dicrotic.  In  the  second  week  the 
fever  becomes  more  pronounced,  the  morning  remission  becoming 
slight  and  the  pulse  no  longer  dicrotic.  At  this  time  it  is  well  to  watch 
for  the  first  signs  of  dryness  at  the  tip  of  the  tongue.  Sometimes, 
but  not  commonly,  hemorrhage  of  the  bowels  or  even  perforation 
occurs  toward  the  end  of  this  week. 

There  is  no  serious  acute  disease,  which,  as  we  shall  see,  is  more 
amenable  to  treatment  than  typhoid  fever,  but,  if  not  properly  treated, 
its  further  course  in  the  third  week  is  marked  by  an  increase  in  the 
pulse  from  no  to  130.  If  it  rises  above  130,  the  prognosis  is  unfavor- 
able in  proportion  to  the  rise.  A  degree  of  bronchitis  may  set  in  very 
early,  so  as  to  obscure  the  diagnosis.  In  unfavorable  cases  we  may 
have  pneumonia  in  the  third  week,  with  a  constant  diarrhea  and  tym- 
panites, but  one  of  the  most  serious  symptoms  is  increasing  feeble- 
ness of  the  heart.  It  is  at  this  time  that  hemorrhage  and  perforation 
may  occur.  The  fever  continues  high,  from  104°  to  106°  F.  A  sudden 
drop  then  in  the  range  of  temperature  is  ominous,  for  it  usually  goes 
with  the  onset  of  hemorrhage.  In  the  fourth  week,  as  a  rule,  conva- 
lescence begins,  but  with  a  considerable  variation  in  the  symptoms, 
even  in  the  milder  cases.  In  severe  cases  the  conditions  are  an  aggra- 
vation of  the  s>Tnptoms  of  the  previous  week,  the  patient  grows  weaker, 
pulse  more  rapid  and  feeble,  the  tongue  dry,  and  the  abdomen  dis- 
tended. The  delirium  becomes  more  muttering  and  continuous,  with 
subsultus  tendinum,  and  the  patients  pass  both  the  urine  and  feces  in 
bed .  Typhoid  fever  does  not  end  by  crisis ,  but  by  lysis ,  very  gradually, 
and  this  condition  may  be  vexatiously  prolonged  iato  the  fifth  or  sixth 
week,  even  though  there  may  be  no  pronounced  relapse.  True  relapses 
usually  occur  after  the  temperature  has  come  down  to  normal,  or  nearly 
normal,  for  two  or  three  days.     Then  the  picture  of  a  new  attack  of 


TYPHOID    FEVER  15I 

typhoid  fever  sets  in,  with  the  same  gradual  rise  of  the  temperature  with 
morning  remissions  until,  in  many  cases,  with  a  reappearance  of  the 
rash,  it  would  be  difficult  not  to  pronounce  the  case  as  a  second  attack 
of  this  specific  fever.  As  a  rule,  however,  the  relapses  are  shorter  in 
duration  and  milder  in  their  course  than  the  original  disease.  The 
physician,  however,  should  be  guarded  in  his  prognosis,  for  in  numerous 
instances  death  occurs  during  the  relapse,  usually  from  progressive 
weakness  or  from  perforation. 

Rather  extensive  changes  occur  in  the  arteries,  the  most  important 
of  which  are  located  in  the  aorta  and  in  the  coronary  arteries,  and 
consist  of  turgescence  of  the  intima  with  scattered  areas  of  deeper  de- 
generations, which  may  lead  to  necroses  in  the  parts  supplied  by  the 
affected  arteries.  The  veins  show  changes  more  frequently  than  the 
arteries,  thrombosis  of  veins  being  particularly  common.  We  may 
have  ulcers  in  the  esophagus  with  a  few  above  in  the  pharynx. 

There  may  be  extreme  emaciation  along  with  bed-sores,  both  of 
which  are  preventable  by  proper  treatment.  The  muscles  are  very 
prone  to  degeneration  due  to  prolonged  course  of  the  fever,  but  other- 
wise the  changes  in  them  are  not  characteristic  only  of  this  disease. 
As  in  other  fevers  the  nervous  symptoms  may  be  very  pronounced; 
these  are  caused  by  no  organic  changes  in  either  brain  or  spinal  cord, 
but  are  altogether  due  to  the  toxemia.  Meningitis  is  uncommon, 
but  does  occur  sometimes  accompanied  by  purulent  exudation.  A 
thin  exudation  may  be  found  at  the  beginning  in  severe  cases  on  the 
tonsils  and  on  the  uvula  and  soft  palate.  The  larynx  is  sometimes 
infected,  beginning  with  superficial  inflammation  of  its  mucous  mem- 
brane, which  may  penetrate  deeper  with  ulceration  and  then  affect 
the  cartilages.  The  majority  of  the  ulcers  are  on  the  posterior  part 
of  the  larynx,  but  may  also  be  at  the  base  of  the  epiglottis.  WTien 
the  cartilages  are  involved,  then  necrosis  may  give  rise  to  serious 
abscesses.  Such  inflammations  do  not  extend  to  the  trachea  and  bron- 
chi. Hypostatic  pneumonia  usually  occurs  from  too  prolonged  decu- 
bitus. Lobar  pneumonia,  on  the  other  hand,  is  not  uncommon,  and 
may  be  due  to  its  usual  agent,  the  pneumococcus,  but  occasionally  has 
been  found  to  be  due  to  the  typhoid  bacillus.  In  my  experience  the 
prognosis  of  such  pneumonia  is  not  very  serious.  Bronchopneumonia 
is  very  common  as  a  sequel  to  early  bronchitis.  This  bronchitis  is 
so  common  at  the  onset  as  to  delay  the  diagnosis  of  typhoid  fever. 
Gangrene  of  the  lung  occurs  as  a  sequel  to  pneumonia,  but  is  not 
common.  Hemorrhagic  infarction,  especially  during  the  later  stages, 
is  not  uncommon.     The  important  cardiac  changes  are  in  the  myocar- 


152  CLINICAL  MEDICINE 

dium,  and  may  constitute  the  most  serious  of  the  complications  of 
the  later  stages  of  the  disease.  Death,  in  fact,  is  often  due  to  this  con- 
dition of  the  heart,  the  heart-muscles  showing  on  section  marked 
parenchymatous  degeneration,  with  a  curiously  characteristic  mottled 
appearance.     Endocarditis  is  rare;  so  also  is  pericarditis. 

The  rash  of  typhoid  fever  is  quite  distinctive  and  differs  from  the 
eruptive  forms  of  other  exanthemata,  like  scarlet  fever,  measles,  and 
small-pox.  It  is  usually  not  nearly  so  extensive,  and  its  rose-spots 
may  have  to  be  carefully  looked  for  and  distinguished  from  ordinary 
papules  or  spots  on  the  skin.  It  also  has  no  certain  date  for  its  appear- 
ance, usually  occurring  at  the  end  of  the  first  week,  though  sometimes 
not  until  in  a  relapse. 

Its  most  common  site  is  on  the  anterior  abdomen,  but  frequently 
on  the  back.  I  have  seen  it,  however,  all  over  the  body.  It  consists 
of  definitely  outlined  rose-spots,  as  they  are  called,  which  disappear 
on  pressure,  but  return  quickly  when  that  is  removed.  The  typhoid 
bacilH  have  been  found  in  these  spots,  one  evidence  of  the  universal 
distribution  of  the  infection.  These  spots  after  disappearing  may  de- 
velop in  other  localities.  The  organ  earliest  affected  is  the  spleen, 
which  is  invariably  enlarged  in  the  early  stages  of  the  disease,  and  this 
enlargement  constitutes  one  of  the  diagnostic  symptoms  of  this  infec- 
tion. This  is  due  to  a  congestion  of  the  tissue,  which  also  produces 
softening  of  its  parenchyma,  so  that  the  organ  may  spontaneously 
rupture. 

By  far  the  most  serious  of  typhoid  changes  occur  in  the  intestine, 
in  which  the  lymphoid  elements  chiefly  at  the  lower  end  of  the  ilium 
are  involved.  These  begin  with  a  hyperplasia,  implicating  the  glands 
of  Peyer  from  the  jejunum  down,  but  chiefly  in  the  lower  end  of  the 
iHum,  and,  to  a  variable  extent,  in  the  large  intestine  as  well.  A  great 
increase  and  accumulation  of  the  cells  in  the  lymph  tissue  occurs,  as  if 
this  tissue  were  especially  stimulated  by  the  typhoid  toxin;  the  cells 
may  so  crowd  upon  one  another  that  the  circulation  and  nutrition  of 
the  part  is  gravely  involved,  leading  to  patches  of  ulceration  which  may 
be  very  irregular  or  extensive.  It  is  from  these  ulcerations  that  the 
more  serious  accidents,  such  as  intestinal  hemorrhage  and  perforation, 
occur.  Both  these  accidents  of  hemorrhage  and  of  perforation  vary 
remarkably,  according  to  seasonal  changes  in  the  epidemics,  the 
causes  of  which  are  obscure ;  during  some  years,  in  my  wards,  these  acci- 
dents were  three  or  four  times  as  numerous  as  in  other  years.  One 
feature,  however,  in  typhoid  intestinal  ulcerations  is  that  in  healing, 
the  ulcers  leave  scarcely  any  scars,  and  do  not  produce  constriction. 


TYPHOID   FEVER  1 53 

of  the  bowel  as  they  do  in  tuberculous  or  other  ulcerative  conditions 
of  the  intestine. 

Treatment. — When  left  to  itself,  or  imperfectly  treated,  typhoid 
fever  is  a  very  serious  complaint.  Thus,  Dr.  Murchison  found  that 
the  mortahty  of  patients  in  the  London  fever  hospital,  during  the  ten 
years  ending  1862,  was  18.5  per  cent.,  and  Dr.  Sidney  Phillips,  in  a 
paper  read  before  the  Harveian  Society  in  November,  1899,  from 
comparison  of  statistics  of  the  London  Hospitals  from  1890  to  1897, 
stated  that  the  mortahty  still  remained  nearly  19  per  cent.  This  is  in 
striking  contrast  with  the  extensive  experience  of  Jurgensen,  in  the 
management  of  this  fever  among  German  army  recruits,  in  which  he 
puts  the  mortahty  at  but  httle  above  2  per  cent.  According  to  my 
recorded  experience  in  hospital  practice  for  the  past  thirty-five  years, 
the  mortahty  should  not  be  much  over  3  per  cent.  Among  those 
patients,  who  gave  us  an  opportunity  to  treat  them,  I  make  this  state- 
ment with  full  recognition  of  the  fact  that  no  such  conclusions  should 
have  weight,  unless  they  are  based  upon  carefully  made  and  recorded 
observations  extending  over  long  periods. 

Typhoid  fever  shares  with  other  acute  infections  a  varying 
severity,  according  to  what  is  termed  the  epidemic  constitution 
of  the  particular  season,  rendering  the  experience  of  one  year 
no  criterion  of  what  it  will  be  the  following  year.  Hospital  sta- 
tistics are  notoriously  untrustworthy  for  drawing  any  conclusions 
as  to  treatment,  because  so  many  of  the  patients  with  typhoid 
fever  are  not  brought  to  the  hospital  until  they  are  far  advanced 
in  the  disease.  Thus,  of  574  patients  in  my  wards  at  the  Roosevelt 
Hospital,  398  males  and  176  females,  with  a  total  number  of  deaths 
40,  or  7.5  per  cent,  of  the  entire  number,  23  or  57  per  cent,  died  within 
the  first  week  after  admission,  and  80  per  cent,  of  these  did  not  survive 
the  fourth  day,  while  no  less  than  7  succumbed  to  perforation  within 
four  days  after  admission.  Statistics  of  mortality,  however,  are  not 
the  only  test  of  the  efficacy  of  any  method  of  treatment,  and  partic- 
ularly so  in  typhoid  fever.  How  the  patients  pass  through  the  attack, 
in  respect  to  the  occurrence  and  to  the  gravity  of  its  various  accom- 
paniments, and  in  what  condition  it  leaves  those  who  recover  from  it, 
are  much  more  satisfactory  indications,  whether  the  disease  is  amen- 
able to  certain  remedial  measures  or  not.  Whether  any  progress, 
therefore,  has  been  gained  in  the  past  thirty-five  years  in  the  manage- 
ment of  typhoid  fever  would  be  best  illustrated  by  a  comparison 
between  the  incidence  and  the  degree  of  the  leading  symptoms  of  ty- 
phoid fever,  as  they  are  described  in  such  text-books  as  Watson  and 


154  CLINICAL  MEDICINE 

Bristowe's  of  forty  years  ago  and  those  found  in  the  chnical  histories 
now  presented.  Thus,  following  Bristowe's  enumeration  of  symptoms, 
we  shall  first  note  the  diarrhea.  He  speaks  of  it  as  generally  associated 
with  the  initial  symptoms,  though  sometimes  absent,  then  to  become 
a  striking  feature  of  the  disease,  and  rarely  absent  from  the  second 
week  on.  He  recommends  to  check  it  by  the  systematic  administra- 
tion of  tannic  acid,  sulphuric  acid,  lead  and  opium,  etc. 

In  my  own  records  diarrhea  occurring  after  the  first  week  is  re- 
ported in  only  39,  or  12  per  cent.,  and  in  the  majority  of  them  it  was 
not  severe,  so  that  there  are  very  few  prescriptions  recorded  as  ad- 
ministered for  this  symptom.  On  the  contrary,  constipation,  which 
has  to  be  reheved  by  enemas,  was  a  frequent  occurrence.  I  ascribe 
this  change,  in  a  large  measure,  to  a  change  in  the  feeding  of  the  patient. 
Thirty  years  ago  the  use  of  beef-tea  in  typhoid  fever  was  almost  uni- 
versal. I  beheve  that  hardly  any  articles  are  so  prone  to  fermentation 
in  the  aHmentary  canal  as  the  continuous  administration,  day  and  night, 
of  meat  broths  in  febrile  conditions. 

Thirty  years  ago  tympanites  was  so  constant  a  symptom  that  it 
was  rated  as  a  diagnostic  feature  of  the  disease.  Dr.  Jenner  states 
that  the  shape  of  the  abdomen  is  invariably  the  same  and  peculiar. 
The  patient  is  never  pot-belhed,  but  tub  shaped.  As  I  have  always 
placed  a  good  deal  of  store  on  this  symptom  I  have  had  its  oc- 
currence noted  in  every  case,  so  that  even  its  temporary  presence 
might  not  be  overlooked.  I  was  somewhat  surprised,  therefore,  to 
find  it  recorded  in  10 1,  or  28  per  cent.  On  reviewing  this  record, 
however,  it  was  found  that  about  40  per  cent,  of  the  whole  number  of 
instances  of  tympanites  occurred  in  September  and  October,  1898,  and 
were  noted  in  39  soldiers  admitted  for  typhoid  fever  contracted  during 
the  Spanish-American  War.  It  was  probably  owing  to  the  reduced 
physical  condition  of  these  soldiers,  from  the  poor  food  and  other  hard- 
ships of  camp  Ufe,  that  they  so  generally  presented  this  symptom  on 
admission.  Deducting,  therefore,  these  soldiers,  the  occurrence  of 
tympanites  is  recorded  in  only  about  62  patients  or  about  26  per  cent. 
Its  presence  is  generally  noted  in  the  histories  of  those  who  were 
admitted  late  in  the  disease,  and  in  the  majority  of  these  it  disappears 
soon  after  under  treatment.  The  prevention  of  this  particular  symp- 
tom, I  beheve,  not  to  be  without  bearing  on  the  question  whether  we 
can  favorably  modify  the  course  of  the  fever,  for  tympanites  is  both  a 
sign  and  a  compHcation.  It  is  a  sign  of  weakened  innovation  and  loss 
of  the  normal  antiseptic  power  of  the  gastro-intestinal  secretions,  and 
also  the  direct  cause  of  cardiac  and  of  pulmonary  circulatory  enfeeble- 


TYPHOID    FEVER  I55 

ment  on  the  other,  while  it  cannot  be  without  some  effect  in  increas- 
ing the  tendency  to  accidents,  such  as  hemorrhage  and  perforation,  at 
the  seats  of  intestinal  ulceration.  I  always  regard  a  persistent  tym- 
panites in  a  typhoid  patient  with  uneasiness,  and  any  treatment  in 
which  this  symptom  becomes  a  rarity  I  cannot  but  consider  as  materi- 
ally beneficial. 

Hemorrhage  from  the  bowels  occurred  in  i  per  cent.  In  no  in- 
stance was  it  directly  fatal,  and  it  was  readily  controlled  by  a  dose  of 
3  pills  at  once  administered  of  the  following  prescription : 

I^.    Argent,  nitratis gr.  v; 

Pulv.  opii gr.  v; 

Terebinthinae  resin oiij; 

Liq.  kali 5j. — M. 

Div.  in  pilul.  Ix. 

The  object  of  the  turpentine  is  to  prevent  the  silver  salt  from 
being  absorbed  until  it  is  well  on  its  way  down  into  the  intestine. 
Sometimes  these  pills  are  voided  unchanged,  in  which  case  they  are 
rubbed  up  with  more  Hcorice  powder  in  the  making.  I  have  used  these 
pills  for  years  in  the  treatment  of  ulcerative  cohtis  or  ulcers  in  chronic 
dysentery,  intestinal  tuberculosis,  etc.,  with  such  good  effects  that  I 
have  no  doubt  that  when  taken  for  intestinal  hemorrhage  they  may 
also  be  of  service  in  preventing  perforation.  After  there  have  been 
no  signs  of  hemorrhage  in  t3^phoid  for  thirty-six  hours  the  baths  are 
again  resumed.  It  is  always,  however,  a  comphcation  of  some  mo- 
ment, because  it  may  oblige  us  to  suspend  the  Brand  bath  at  a 
critical  period  of  the  hyperpyrexia. 

In  the  third  and  fourth  weeks  the  patients  are  often  restless  from  a 
general  aching  of  the  body.  This  is  due  to  the  absorption  of  the  sub- 
cutaneous cushion  of  fat,  leaving  the  nerves  which  never  waste  so  ex- 
posed to  pressure  against  the  bones  at  the  sacrum,  scapula,  knees, 
etc.,  that  intolerable  neuralgic  pains  often  result.  This  aching  is 
remarkably  reHeved  and  sleep  thereby  promoted  by  spreading  sheep- 
skins with  the  wool  on  them  or  buffalo  robes  on  the  bed  and  over  these 
a  sheet  for  the  patient  to  He  upon.  In  all  conditions  of  emaciation 
such  measures  to  relieve  pressure  on  nerves  should  be  employed. 
Rubbing  the  patient  all  over  with  warm  hme-water  liniment,  to  which 
cinnamon  oil,  i  dram  to  the  pint,  has  been  added,  is  very  soothing 
after  the  second  week,  and  if  well  apphed  to  the  back  twice  a  day  is 
a  good  prophylactic  against  bed-sores. 

One  man,  while  sitting  up  convalescent  on  the  thirty-second  day  of 


156  CLINICAL  MEDICINE 

his  disease,  began  to  bleed  from  nearly  every  mucous  membrane 
of  his  body.     He  died  after  two  days  from  excessive  hematuria. 

Among  the  31  deaths  of  male  patients,  7  succumbed  to  intestinal 
perforation.  One  of  these  cases  was  that  of  a  boy  who  had  been  in 
the  hospital  ten  days.  All  the  others  occurred  in  patients  who  had 
been  there  less  than  a  week  after  admission.  The  boy  was  operated 
upon  and  recovered.     Five  others  were  operated  upon,  but  died. 

To  continue  our  comparison  with  descriptions  of  former  text-books, 
Dr.  Bristowe  proceeds  to  describe  the  classical  typhoid  condition,  into 
which  he  states  a  large  proportion  of  the  cases  pass  in  the  second  week. 
The  elevation  of  the  temperature  continues,  the  rash  still  comes  out, 
the  diarrhea  still  persists,  the  tongue  becomes  dry  and  brown  and  trav- 
ersed by  deep  fissures,  the  Hps  and  teeth  covered  with  sordes,  the 
mind  grows  dull  and  apathetic,  and  delirium,  sometimes  violent,  some- 
times busy,  sometimes  muttering,  supervenes.  Tremors,  subsultus 
and  involuntary  passage  of  evacuations  take  place,  etc. 

I  have  no  hesitation  in  saying  that  our  present  forms  of  treatment 
have  done  away  with  the  typhoid  condition  here  described  so  entirely 
that  repeatedly  my  successive  house  physicians  have  told  me  that  they 
had  not  seen  cases  of  the  kind  and  would  have  to  go  elsewhere  to  find 
them.  That  this  picture  of  a  patient's  state  should  become  a  rarity 
is  certainly  an  evidence  of  improved  therapeutics,  as  is  shown  by  the 
following  reports  of  the  incidence  of  its  constituent  symptoms.  Thus, 
as  to  dehrium,  out  of  the  whole  number  admitted  to  my  wards  it  was 
noted  in  60,  or  16  per  cent.,  but  of  these  26,  or  nearly  50  per  cent., 
were  dehrious  on  admission,  12  of  whom  died  within  that  week,  whereas 
the  rest  recovered  from  their  delirium  within  a  week  or  less.  The 
entire  absence  of  dehrium  at  any  period  of  their  illness  in  the  remain- 
ing 517  patients,  or  94  per  cent,  of  the  whole  number,  is  at  least  an 
indication  that  they  hardly  passed  into  Bristowe's  so-called  typhoid 
state  at  any  time  in  the  course  of  the  disease;  while,  on  the  other 
hand,  nothing  testifies  so  clearly  to  the  benefits  of  treatment  as  the 
absence  of  all  signs  of  mental  disturbance  in  the  majority  of  these 
ward  patients.  The  state  of  the  tongue  was  always  carefully  noted, 
but  fissure  is  not  once  recorded;  sordes  on  the  teeth  and  lips  were 
present  in  some  patients  on  admission,  but  in  every  case  soon  disap- 
peared, and  is  never  recorded  as  developing  in  patients  after  admission. 
It  has  seemed  to  me  that  a  remedy  soon  to  be  mentioned  is  quite  effi- 
cacious in  preventing  dryness  of  the  tongue  if  administered  at  the 
first  appearance  of  this  symptom  at  the  tip. 

Of  other  compHcations  in  our  series  pneumonia  occurred  in  11,  or 


TYPHOID   FEVER  I57 

1.9  per  cent. ;  bronchitis,  in  56,  or  18  per  cent.  It  was  an  initial  symp- 
tom in  over  40  per  cent.,  but  was  easily  controlled. 

Peripheral  neuritis  occurred  in  28  or  not  quite  7  per  cent.,  and  in 
each  case  was  limited  to  the  feet.  The  causation  of  this  symptom  in 
typhoid  is  apparently  purely  mechanical  from  the  foot-drop  induced 
by  prolonged  relaxation  of  the  leg  muscles,  thus  causing  the  nerves  to 
be  put  upon  a  continuous  stretch  and,  therefore,  I  am  always  particular 
that  the  feet  have  a  foot-rest  in  the  third  week,  with  care  that  the 
weight  of  the  bedclothes  should  be  taken  off  them  by  a  cradle.  Neglect 
of  these  precautions  may  make  the  recovery  of  the  power  of  walking 
very  slow  during  convalescence.  The  best  local  apphcation  to  reheve 
the  tenderness  and  pain  in  the  feet  is  to  wrap  them  up  twice  a  day, 
for  half  an  hour,  in  cloths  wet  with  an  infusion  of  red  pepper,  i  dram  to 
the  pint  of  hot  water. 

Phlebitis  occurred  in  1 1 ;  in  2  of  them  it  was  very  troublesome  and 
much  prolonged  in  convalescence.  Local  appHcations  of  the  strong 
tincture  of  iodin  or  of  silver  nitrate,  20  gr.  to  the  ounce,  should  be 
appHed  over  the  affected  vein  very  early. 

Relapses  occurred  in  62  or  no  less  than  18  per  cent,  of  all  cases, 
though  some  of  them  seemed  to  occur  in  close  sequence  to  some  im- 
prudence in  eating  during  the  hungry  period  of  convalescence,  yet  in 
many  instances  no  such  cause  could  be  assigned.  Moreover,  the 
tendency  to  relapse  is  much  more  marked  in  certain  years  than  in 
others,  rising  in  one  year  to  30  per  cent,  of  all  cases,  so  that  the  etiology 
of  these  recrudescences  is  obscure.  It  seems  to  me,  however,  that 
relapses  are  more  frequent  in  that  class  of  patients  in  whom  the 
brunt  of  the  attack  appears  to  fall  on  the  intestine,  more  so  than  with 
those  characterized  in  the  beginning  with  a  tendency  to  hyperpyrexia. 
A  patient  with  the  symptoms  of  pronounced  abdominal  lesions,  such 
as  persistent  tympanites  and  tongue  tremor,  should  not  be  allowed 
soHd  food  in  any  form  for  ten  days  after  his  temperature  has  fallen 
to  normal. 

The  treatment  of  typhoid  fever  should  be  of  a  general  kind,  to  be 
prescribed,  in  all  its  details,  for  every  case  from  the  beginning,  no  mat- 
ter how  mild  the  attack  may  seem  to  be,  for  we  are  never  sure  that 
a  mild  case  may  not  develop  severe  symptoms.  The  treatment  also 
should  be  of  a  particular  kind,  according  to  the  special  tendencies 
developing  in  the  course  of  the  disease.  Those  special  tendencies 
should  be  early  recognized  and  definitely  dealt  with,  for  routine 
treatment  is  no  more  justifiable  in  typhoid  than  in  any  other  serious 
complaint. 


158  CLINICAL   MEDICINE 

The  general  line  of  trecdment,  which  in  the  majority  of  cases  is  the 
only  treatment  needed,  I  would  prescribe  as  follows: 

First,  early  attention  to  the  state  of  the  kidneys  during  the  first 
week  or  ten  days,  as  there  is  a  marked  tendency  to  a  diminution  in  the 
secretion  of  urine.  This  I  regard  as  an  initial  complication,  whose 
effects  may  render  the  subsequent  course  much  more  severe  perhaps 
by  favoring  the  increased  multipHcation  of  the  typhoid  bacillus  in  the 
blood,  owing  to  the  retention  of  excrementitious  matter  from  the  early 
failure  of  renal  ehminations. 

Late  researches  show  that  the  typhoid  bacilh,  instead  of  developing 
only  locally  in  the  intestine,  may  charge  the  blood  as  early  as  the  end 
of  the  first  week.  I  would  recommend,  therefore,  a  recourse  in  these 
cases,  for  the  first  two  weeks  of  the  fever,  to  the  most  certain  diuretic 
which  we  possess,  namely,  rectal  irrigation  with  hot  normal  saline 
twice  a  day.  Kemp's  rectal  irrigator  is  the  best  instrument  for  this 
purpose  that  I  know  of,  using  with  it  4  gallons  each  time  at  a  tempera- 
ture of  1 1 5  °  to  1 20°  F.  The  flow  should  run  out  as  fast  as  it  runs  in,  and 
it  so  constantly  increases  the  urinary  secretion  that  I  have  no  doubt, 
from  numerous  comparative  observations  between  those  who  had  it 
and  those  who  were  without  it,  the  course  of  the  fever  is  distinctly 
changed  for  the  better  by  this  measure. 

In  some  cases  acute  nephritis  develops  comparatively  early  in 
the  disease,  and  then  constitutes  a  serious  complication,  with  a  tend- 
ency to  death  from  uremic  coma  with  pulmonary  edema,  the  causa- 
tion of  this  comphcation  being  a  septic  invasion  of  the  kidneys  by 
the  Bacillus  coH,  and  should  be  promptly  dealt  with  by  the  administra- 
tion of  10  gr.  of  urotropin  along  with  10  gr.  of  sodium  benzoate.  It  is 
striking  to  note  how  soon  this  remedy  lessens  the  percentage  of  albumin 
in  the  urine,  and  also  lessens  the  number  of  casts. 

One  of  the  best  procedures  in  the  first  stage  of  the  fever  is  intes- 
tinal disinfection  by  a  calomel  purge,  given  every  other  night,  until  the 
middle  of  the  third  week.  My  usual  dose  is  5  gr.  of  calomel  and  35  gr. 
of  compound  jalap  powder.  It  promptly  stops  diarrhea,  if  that  be 
present,  and  is  remarkable  for  lowering  the  febrile  temperature  in  the 
second  week  often  from  i  to  3  degrees,  compared  with  its  previous 
range.  It  acts  well  also  in  the  promotion  of  the  secretion  of  urine. 
It  should  be  omitted,  however,  after  the  twentieth  day,  owing  to  the 
risk  of  hemorrhage  from  cathartics. 

The  next  measure  which  I  would  mention  is  the  systematic  use 
of  the  cold  bath,  sometimes  called  the  "Brand."  I  might  almost  say 
that  without  this  bath  I  would  hardly  try  to  treat  a  severe  case  of 


TYPHOID    FEVER  1 59 

typhoid  fever.  The  reasons  for  this  measure  should  be  clearly  stated. 
Careful  observations,  in  every  part  of  the  world,  have  shown  that  a 
chief  result  of  the  cold  bath  is  greatly  to  increase  the  toxicity  of  the 
urine  passed  immediately  after  the  bath,  thus  showing  that  the  bath 
causes  active  ehmination  by  the  kidneys  of  poisons  in  the  blood.  It  is, 
therefore,  by  no  means  only  through  the  reduction  of  temperature 
that  the  cold  bath  is  so  beneficial.  One  effect  of  immersing  the  body 
in  cold  water  is  at  first  to  raise  the  temperature,  which  rise  is  caused 
by  the  cool  blood  of  the  surface  being  driven  into  the  internal  organs, 
whose  temperature  is  always  from  i  to  3  degrees  higher  than  the  tem- 
perature of  the  surface.  It  is  always  well  to  begin  with  a  bath  the 
temperature  of  which  is  not  lower  than  97°  F.  so  as  to  prevent  shock. 
While  in  the  bath,  the  attendant  should  actively  rub  the  patient,  and 
this  measure  should  never  be  omitted.  Meantime,  by  a  thermometer 
placed  under  the  tongue,  the  temperature  should  be  read  every  two  or 
three  minutes,  to  be  ready  to  remove  the  patient  whenever  a  fall  of 
2  to  3  degrees  in  four  minutes  has  happened;  because  in  every  case 
the  temperature  goes  on  falhng  after  the  patient  has  been  returned  to 
bed,  especially  in  the  case  of  children.  Apphcation  of  cold  to  the 
head  while  in  the  bath  should  not  be  neglected,  preferably  by  an 
ice-bag,  wrapped  in  one  or  two  layers  of  cotton  cloth.  The  bene- 
ficial effects  of  the  bath,  when  properly  administered,  are  unmis- 
takable. If  delirium  has  been  present,  this  subsides,  and  not  infre- 
quently the  patient  falls  into  a  short,  refreshing  sleep,  while  the  pulse 
improves  and  he  grows  calmer.  The  subsequent  course  varies  with 
each  patient.  In  severe  cases  the  fever  soon  returns,  so  as  to  reach 
103°  F.  in  an  hour.  In  many  cases  of  hyperp3rrexia  I  have  ordered 
twelve  baths  in  twenty-four  hours  before  the  fever  would  give  in.  With 
these  precautions  (above  detailed)  one  need  never  fear  giving  too  many 
baths.  In  one  case  I  kept  the  patient  in  the  bath  for  thirty-seven 
minutes  before  the  temperature  would  fall,  but  then  it  came  down, 
and  from  then  on  he  made  an  uninterrupted  recovery.  Ordinarily, 
however,  patients  do  not  require  more  than  four  baths  a  day.  The  rule 
still  remains  the  same  as  at  the  beginning,  that  so  soon  as  the  tempera- 
ture reaches  103°  F.  the  bath  should  be  resumed.  It  is  not  uncom- 
mon for  attacks  of  shivering  to  come  on  before  or  when  the  patient 
is  taken  out  of  the  bath.  This  is  best  treated  by  giving  a  teaspoonful 
of  Hoffmann's  anodyne  or  compound  spirits  of  sulphuric  ether  in  an 
ounce  of  camphor-water. 

One  consideration  of  prime  importance  is  to  maintain  the  nutri- 
tion of  the  patient  throughout  this  wasting  fever.    The  patient  after  the 


l6o  CLINICAL  MEDICINE 

usual  course  of  four  weeks  of  this  fever  should  ordinarily  appear  emaci- 
ated, but  I  have  often  heard  it  remarked  by  visitors  that  my  typhoid 
cases  could  not  have  been  very  sick  because  they  looked  so  well.  But 
under  ordinary  treatment  they  are  frequently  so  much  reduced  and 
emaciated  that  bed-sores  form  on  the  sacrum,  scapute,  or  where  the 
knees  come  together,  all  due  to  the  disappearance  of  the  subcutaneous 
cushion  of  fat  which  protects  the  skin  from  pressure  by  the  subjacent 
bones.  In  some  cases  which  were  admitted  late  in  the  disease  the 
skin  along  the  back  already  showed  signs  of  incipient  bed-sores. 
For  these  I  would  prescribe  an  ointment  composed  of  i  dram  of  tan- 
nate  of  lead,  with  2  gr.  of  salicylic  acid  to  i  oz.  of  simple  cerate,  to 
be  spread  thickly  on  a  cloth,  and  the  whole  covered  with  cotton 
batting,  to  take  off  the  pressure. 

The  first  indication,  however,  is  properly  to  feed  the  patient. 
It  should  be  remembered  that  typhoid  fever,  as  shown  by  Fenwick, 
destroys  the  property  of  the  stomach  to  secrete  pepsin  more  than 
any  other  wasting  disease,  not  excepting  phthisis  or  gastric  cancer. 
The  stomach  of  the  patient,  therefore,  is  reduced  to  more  than  the 
weakness  of  infancy  for  digesting  milk.  Milk,  however,  is  the  only 
food  that  we  can  use  with  safety,  and  it  should  be  prepared  so  that 
the  patient  can  take  it  continuously.  I  have  directed  that  equal 
parts  of  milk  and  lime-water  should  be  administered  night  and  day, 
in  wine-glass  doses,  to  be  repeated  as  often  as  the  patient  will  take  it. 
Besides  the  milk  and  Hme-water  the  patient  should  take  10  gr.  of 
saccharated  pepsin  and  from  10  to  20  gr.  of  bismuth  subcarbonate 
every  three  hours  through  the  twenty-four.  No  other  medication  is 
usually  prescribed. 

I  rarely  prescribe  alcohol  in  any  form  in  the  treatment  of  t5^hoid 
fever.  Occasionally,  however,  with  those  admitted  late  in  the  disease, 
it  is  necessary.  It  is  a  common  mistake  to  give  alcohol  too  continuously 
during  the  complaint.  It  should  be  administered  only  occasionally, 
and  then  in  actually  stimulating  doses  of  from  ^  to  i  oz.  of  whisky  in 
the  milk  and  hme-water.  My  custom  is  to  direct  it  only  after  3 
o'clock  in  the  afternoon,  if  not  to  postpone  it  altogether  until  after 
midnight.  In  conditions  of  great  weakness  of  the  heart,  strychnin 
and  caffein  may  be  tried.  But  the  real  heart  stimulant  to  sustain  this 
faihng  organ  the  best  is  the  hypodermic  injection  of  camphor  in  ster- 
ilized almond  oil,  as  before  mentioned. 

During  the  convalescence  it  is  important  to  know  when  and 
how  long  the  patient  may  be  allowed  to  sit  up.  Many  sudden  deaths 
have  occurred  from  cardiac  weakness  in  convalescents,  and  I  have 


ASIATIC   CHOLERA  l6l 

known  of  more  than  one  instance  of  permanent  injury  to  the  heart 
from  patients  rising  and  going  about  too  soon  after  typhoid  fever. 
The  safe  rule  is  to  take  the  pulse  of  the  patient  while  he  is  lying  down, 
and  then  counting  the  frequency  when  he  sits  up.  Normally,  the 
pulse  should  increase  only  lo  beats  on  rising,  but  if  it  increases  50 
beats  he  should  not  think  of  sitting  up  or  walking.  I  kept  a  patient 
once  for  two  months  in  bed  because  his  pulse-rate  would  not  fall  to 
the  normal  ratio  between  the  recumbent  and  erect  posture. 

PARATYPHOID  FEVER 

Besides  the  typhoid  bacillus  there  are  other  related  organisms 
w^hich  cause  their  own  special  disorders.  First  among  these  we  would 
mention  the  paratyphoid  bacillus,  which  causes  a  fever  very  closely 
resembling  typhoid  fever,  both  in  its  symptoms  and  its  course.  The 
differential  diagnosis  from  typhoid  fever  can  only  be  settled  by  an 
examination  of  the  blood,  which  will  show  the  presence  of  the  para- 
typhoid bacillus.  This  organism  presents  characteristic  differences 
in  culture-media  from  Eberth's  bacillus,  and,  cliQically,  the  fever  which 
it  occasions  differs  from  typhoid  fever  in  running  a  much  shorter  course. 
Formerly,  owing  to  this  fact,  cases  were  frequently  mentioned  of  abort- 
ive typhoid  fever,  because  paratyphoid  fever  can  run  its  course  in 
from  ten  to  fourteen  days,  and  usually  that  course  is  milder  than  un- 
complicated typhoid  fever.  In  treatment  it  differs  in  no  respect  from 
that  caused  by  Eberth's  bacillus. 

MEAT-POISONING 

Very  different  and  far  more  serious  in  its  effect  is  the  derange- 
ment caused  by  Gartner's  Bacillus  enteritidis.  This  organism  has  been 
identified  as  the  cause  of  several  local  outbreaks  of  meat-poisoning,  so 
named  because  the  patients  have  partaken  of  the  same  kind  of  butcher 
meat,  whether  beef  or  pork.  The  symptoms  of  this  infection  are  vio- 
lent derangements  of  the  intestine,  frequently  with  discharges  of 
blood,  and  rapid  involvement  of  the  nervous  system.  This  affection 
was  first  identified  by  Gartner,  who,  besides  demonstrating  its  origin 
from  a  particular  bacillus  which  he  called  "Bacillus  enteritidis,"  was 
able  to  isolate  its  toxin,  which  is  remarkable  for  its  great  resistance  to 
heat.    No  antidote  to  this  bacillus  has  yet  been  discovered. 

ASIATIC  CHOLERA 

In  the  year  1885  the  Massachusetts  Board  of  Health  issued  a  state- 
ment intending  to  reassure  the  pubHc  about  the  nature  of  Asiatic 
11 


1 62  CLINICAL   MEDICINE 

cholera  which  then  began  to  be  epidemic  in  Boston.  In  this  state- 
ment they  strongly  insisted  that  Asiatic  cholera  was  not  at  all  a  con- 
tagious disease,  but  was  due  to  a  miasm  pervading  the  atmosphere. 
Both  these  statements  were  mischievous  errors,  because  it  was  then 
understood  that  in  denying  that  Asiatic  cholera  was  contagious  it  was 
also  intended  to  deny  that  it  was  communicable  from  person  to  person, 
whereas  the  truth  is  that  this  disease,  though  not  properly  contagious, 
is  always  communicated  from  the  sick  to  the  well.  We  know  also  that 
the  second  statement  was  equally  erroneous,  as  there  is  no  miasm;  for 
even  the  disease  called  by  its  ancient  name — "malaria"  or  bad  air — we 
now  know  is  an  infection  caused  solely  through  a  hypodermic  injec- 
tion by  a  mosquito.  The  whole  conception  of  the  deadly  miasms  aris- 
ing from  swamps  and  unhealthy  locaUties,  which  for  ages  has  weighed 
upon  the  medical  mind,  is  a  mistake,  and  therefore  there  are  no  un- 
healthy locahties  or  unhealthy  climates  as  such,  but  only  regions  in- 
fected by  a  certain  variety  of  mosquito,  which  medical  science  knows 
now  how  to  disinfect  and  render  as  healthy  as  any  other  climate. 

Had  the  Massachusetts  State  Board  of  Health  only  perused  the 
reports  pubhshed  by  the  Government  of  Denmark  on  the  epidemic  of 
cholera  in  that  kingdom  in  the  year  1853  they  would  at  once  have 
known,  as  the  profession  ever  since  has  known,  that  cholera  does  spread 
from  person  to  person  and  in  no  other  way,  and  is  never  disseminated 
through  the  atmosphere.  This  was  proved  by  the  Danish  Govern- 
ment issuing  directions  to  all  physicians  practising  in  country  districts 
in  Denmark  to  report  the  first  case  of  cholera  occurring  in  their  rural 
neighborhood.  Then  the  second,  third,  and  fourth,  up  to  the  fifth 
case  was  reported.  Having  collected  these  reports,  it  was  shown  that 
the  case  of  each  second,  third,  and  fourth  patient  could  in  some  way  be 
traced  as  having  had  some  communication  with  the  first  patient; 
although  in  one  instance  a  laundress  who  had  washed  the  clothes  of  a 
cholera  patient  was  taken  sick,  though  she  never  saw  the  patient  and 
lived  ten  miles  from  him. 

This  leads  me  to  say  that  this  fact  affords  a  valuable  illustration 
of  how  country  practitioners  may  greatly  assist  their  profession  by 
systematic  observation  of  the  epidemic  prevalence  of  certain  infec- 
tions when  occurring  in  isolated  communities.  They  may  be  the  only 
men  who  can  give  satisfactory  observations  on  many  infections,  such 
as  epidemic  poHomyelitis,  compared  with  those  who  practice  in  large 
cities  where  crowds  are  often  assembled,  making  it  impossible  to 
detect  infected  persons,  compared  to  patients  in  country  districts  where 
every  one  can  personally  know  his  neighbors. 


ASIATIC   CHOLERA  1 63 

Asiatic  cholera  is,  like  typhoid  fever,  a  typical  illustration  of  an 
infection  indirectly  communicated,  and  hence  not  at  all  contagious. 
Its  chief  chnical  feature  is  a  rapid  draining  of  the  blood-serum  produced 
by  abundant  evacuation  from  the  bowels  as  well  as  by  vomiting.  It  is 
interesting  to  note  that  experimental  excision  of  the  solar  plexus  is 
followed  by  a  diarrhea  closely  resembhng  that  of  Asiatic  cholera.  As 
we  know  that  the  specific  agent  of  cholera  does  not  enter  the  blood,  but 
grows  on  a  large  scale  in  the  intestine,  it  would  seem  as  if  a  cholera 
toxin  absorbed  by  the  blood  causes  a  paralysis  of  the  abdominal  s}Tn- 
pathetic. 

The  identification  of  the  causative  agent  of  cholera  was  made  by 
Robert  Koch  in  1883,  and  his  name  will  always  be  celebrated  for  those 
two  great  discoveries  of  the  Bacillus  tuberculosis  and  of  the  cholera 
germ  within  the  short  period  of  three  years.  Koch  conclusively  showed 
that  this  disease  is  caused  by  a  microbe  which  he  called  the  comma 
bacillus,  which  is  a  short,  somewhat  thick  and  curved  organism  closely 
resembling  a  comma  in  writing.  Sometimes  two  of  these  bacilh  are 
joined  by  their  bases  so  as  to  resemble  the  letter  "s."  Its  toxin  is  in- 
tracellular. It  grows  in  vast  numbers  on  the  mucous  surface  of  the 
intestine,  but  in  chronic  cases  digs  down  into  the  Lieberkiihn  follicles. 
In  the  flux  are  suspended  portions  of  the  shed  epithelium,  so  as  to  give 
rise  to  the  term  "rice-water  discharges." 

There  can  be  no  doubt  that  cholera  has  existed  in  its  native  haunts 
in  India  from  remote  times,  yet  it  is  difficult  to  account  for  the  fact  that 
it  did  not  take  the  form  of  a  world  epidemic  until  the  year  181 7.  Since 
that  time  it  has  repeatedly  invaded  all  countries  in  Asia,  Europe,  Africa, 
and  America,  its  march  being  from  east  to  west,  and  strictly  following 
the  routes  of  commerce  or,  in  the  Oriental  lands,  the  tracks  of  pil- 
grimages. 

The  present  generation  hardly  knows  how  the  dread  specter  of 
this  epidemic  once  made  all  the  western  nations  tremble  when  the  news 
came  that  it  had  started  afresh  on  its  travels  from  its  native  India. 
The  British  Government  had  discovered  there  that  its  chief  outbursts 
coincided  with  the  great  Hindu  pilgrimage  which  occurred  once  in 
twelve  years  to  Hardwar,  on  the  Ganges.  How  cholera  might  abound 
on  such  an  occasion  is  well  shown  in  the  description  by  Dr.  Simpson, 
the  able  health  officer  of  Calcutta:  "At  this  pilgrimage,  which  is  also 
held  as  a  fair,  from  800,000  to  1,000,000  Hindus  collect  to  drink  the 
holy  waters  of  their  sacred  Ganges,  and  to  bathe  in  the  great  tank 
constructed  at  the  riverside.  From  April  8  to  April  12,  1891,  it  pre- 
sented the  spectacle  of  a  seething  mass  of  humanity  in    constant 


164  CLINICAL  MEDICINE 

motion  through  the  pool  at  the  rate  of  400  to  500  per  minute."  Now  it 
can  easily  be  imagined  that  a  few  cases  of  cholera  introduced  into  such 
a  multitude  would  easily  induce  not  only  an  outbreak  of  cholera  there 
and  then,  but  would  be  carried  far  and  wide  by  returning  pilgrims. 
Thus  a  sanitary  commissioner  says  of  previous  Hardwar  gatherings 
that  very  little  remains  on  record,  but  that  little  is  a  record  of  disease 
and  death.  So  grave  was  the  outlook  that  the  question  of  prohibiting 
the  pilgrimage  in  1891  was  seriously  discussed,  and  many  officials  of 
great  experience  reported  that  the  most  complete  sanitary  arrangements 
would  be  powerless  to  prevent  the  spread  of  cholera  if  the  fair  was  held. 

As  this  prohibition  might  entail  the  danger  of  a  general  insur- 
rection, the  British  Government  decided  to  hand  the  management  of 
it  over  to  the  Indian  medical  staff.  The  latter,  now  knowing  just  how 
cholera  infects,  and  that,  without  being  swallowed  in  food  or  drink,  it 
cannot  travel  six  inches,  allowed  the  fair  to  be  held.  They  promptly 
removed  to  appointed  tents  every  case  of  the  disease  in  this  Asiatic 
crowd  as  soon  as  reported.  All  discharges  from  the  patients  were 
quickly  disinfected,  with  the  result  that  the  cholera  was  stamped  out 
as  effectually  as  a  fire  can  be  extinguished  if  taken  just  at  its  beginning. 

Like  typhoid  fever,  it  is  a  water-borne  disease.  This  was  strikingly 
illustrated  in  the  great  epidemic  in  the  city  of  Hamburg  in  1892.  The 
inhabitants  on  one  side  of  a  street  were  severely  affected,  while  those 
on  the  opposite  side  of  the  street  almost  wholly  escaped,  the  explanation 
being  that  houses  of  the  affected  side  were  supphed  by  the  contaminated 
water  of  the  river  Elbe,  while  on  the  other  side  the  houses  were  supplied 
by  the  uncontaminated  aqueduct  of  the  suburb  Altuna. 

Symptomatology. — The  course  of  the  attack  may  be  divided  into 
three  stages:  the  first  is  that  of  diarrhea,  commonly  painless,  but  some- 
times accompanied  with  considerable  griping.  The  next  stage  is  that 
of  collapse,  which  may  follow  in  only  a  very  few  hours,  though  ordi- 
narily it  continues  for  the  greater  part  of  the  day.  In  some,  however, 
the  poisoning  is  so  overwhelming  that  the  patients  die  outright  without 
any  diarrhea.     These  cases  are  called  cholera  sicca. 

Along  with  the  purging  there  soon  follows  profuse  vomiting,  in  which 
the  stomach  contents  present  are  first  ejected,  to  be  followed  by  great 
quantities  of  a  tasteless  fluid.  Soon  afterward  the  patient  passes 
into  a  state  of  typical  collapse  similar  to  that  accompanying  fatal  hem- 
orrhage; in  fact,  the  patient,  in  one  sense,  does  bleed  to  death,  for  the 
vomiting  and  purging  so  deplete  the  blood  of  its  serum  that  the  remain- 
ing corpuscular  elements  of  the  blood  cause  it  to  become  very  con- 
centrated.    This  leads  to  another  characteristic  symptom  of  painful 


ASIATIC   CHOLERA  1 65 

cramps  of  the  muscles,  particularly  of  the  extremities.  It  should  be 
borne  in  mind  that  in  every  case  where  the  muscles  are  rapidly  deprived 
of  blood,  tonic  muscular  cramps  are  induced.  In  this  stage,  as  might  be 
expected,  the  pulse  becomes  very  small  and  then  hardly  perceptible  at 
the  wrist.  The  temperature  falls,  and  in  the  axilla  may  not  be  above 
90°  F.,  though  in  the  rectum  it  may  be  103°  F.  or  more. 

Similarly,  the  respirations  become  hurried  and  shallow,  and  the 
voice  husky,  if  not  suppressed.  The  effect  on  the  brain  varies:  in 
many  cases  the  intelligence  is  preserved  to  the  last,  the  patient  show- 
ing a  pecuHar  apathy,  while  in  other  cases  coma  sets  in  early. 

If  the  patient  recovers  from  the  state  of  collapse,  the  pulse  be- 
gins to  return  to  the  wrist,  the  features,  which  have  become  shrunken, 
resume  their  natural  aspect,  and  the  cold,  clammy  surface  again  feels 
normal.  This  stage  of  reaction,  however,  is  often  accompanied  by 
dangers  of  its  own,  for  the  kidneys,  whose  secretion  has  been  entirely 
suppressed  during  the  state  of  collapse,  may  fail  to  perform  their  nat- 
ural functions,  and  acute  nephritis  invohdng  the  tubules  and  paren- 
chyma supervenes;  so  death  is  caused  by  uremia.  Other  accidents 
also  develop  in  the  parenchyma  of  different  viscera,  especially  the 
liver,  so  that  while  many  cases  recover  rapidly  from  the  disease,  with 
others  the  convalescence  is  very  tedious. 

The  mortality  in  this  formidable  epidemic  is  always  high,  ranging 
from  20  to  80  per  cent,  of  those  attacked. 

Treatment. — We  have  no  antidote  against  cholera  any  more  than 
in  other  fatal  infections  which  cause  death  by  the  absorption  of  the 
toxins  rather  than  the  infecting  agents  themselves.  What  we  can  do 
is  to  deal  with  the  comphcatiohs,  and  whatever  we  attempt  must  be 
done  promptly,  for  the  time  rapidly  passes  in  which  we  can  do  anything. 
The  first  of  these  complications  is  heart  failure  in  the  stage  of  collapse, 
and  for  this  purpose  our  only  recourse  is  to  hypodermic  injections  of 
camphor  in  sterilized  almond  or  olive  oil.  These  injections  should 
contain  |  gram  or  7I  grains  of  camphor  to  the  syringeful,  and  may  be 
repeated  every  two  hours.  The  next  complication  is  the  drainage  of 
the  blood  of  its  serum,  caused  both  by  the  purging  and  the  vomiting 
of  the  disease.  The  most  effective  measure  for  this  is  by  hypodermic 
enteroclysis.  For  this  purpose  8  oz.  of  normal  saline  can  be  slowly 
injected  into  the  abdominal  tissues  of  either  flank  of  the  abdomen. 
Along  with  this,  notwithstanding  the  purging,  attempts  should  be 
made  to  administer  i  to  2  gallons  of  normal  saline  by  Kemp's  rectal 
irrigator,  for,  however  active  the  diarrhea,  this  measure  will  allow 
of  a  certain  amount  of  absorption  of  the  saHne  by  the  blood.     It  may 


1 66  CLINICAL   MEDICINE 

be  well  at  this  time  to  try  to  allay  the  peristalsis  of  the  bowel  with 
hypodermic  injections  of  morphin,  the  dose  of  which  is  to  be  left  to  the 
discretion  of  the  physician.  In  the  after-treatment  of  the  case  the 
most  serious  comphcation  is  in  the  condition  of  the  kidneys,  and  here, 
again,  the  persistent  use  of  the  rectal  irrigator  should  be  continued. 
Toward  the  end  of  this  treatment  the  irritabihty  of  the  stomach  may 
be  allayed  by  drop  doses  of  Fowler's  solution  of  arsenic,  given  every 
fifteen  minutes  until  six  doses  have  been  taken. 

ANTHRAX 

Anthrax  is  particularly  interesting  as  the  first  disease  whose 
specific  micro-organism  was  identified  by  Rayer  and  Davaine  in  1850. 
It  is  a  disease  which  is  transmitted  to  man  from  animals,  and  is  also 
remarkable  for  the  survival  of  its  spores,  which  are  not  killed  by  a 
number  of  disinfectants  invariably  fatal  in  other  infections.  Due 
to  the  resistance  of  its  spores,  the  carcasses  of  infected  animals  should 
be  burned,  because  though  buried  deeply  in  the  ground  they  have 
nevertheless  caused  infection  of  cattle.  On  that  account  Pasteur 
suggested  that  the  disease  is  propagated  by  earthworms  infected  at 
difl'erent  levels  under  the  ground.  In  man  the  infection  comes  acci- 
dentally to  those  who  handle  the  hides  or  wool  of  animals  who  have 
died  from  the  disease,  and  hence  it  was  known  for  some  time  in 
England  as  woolsorters'  disease. 

The  appearance  of  its  bacilH  is  very  distinctive,  being  often  the 
length  equal  to  the  diameter  of  a  red  blood-corpuscle.  They  are  non- 
motile  and  occur  either  singly  or  in  groups.  As  seen  in  man,  they 
appear  on  the  surface  of  the  seat  of  inoculation  as  pimples,  which 
soon  become  vesicular  with  an  angry  and  infiltrated  base,  the  tis- 
sues around  them  rapidly  swelling,  with  a  tendency  to  gangrene  of  the 
summit,  surrounded  by  a  purphsh  eschar  and  a  spreading  zone  of 
infiltration,  rendering  it  quite  diagnostic,  the  name  then  often  given 
to  it  being  mahgnant  pustule.  When  the  pustule  first  forms  with 
its  circumjacent  edema  the  temperature  may  rise  rapidly,  but  within 
twenty-four  to  thirty-six  hours  it  falls,  in  many  cases  below  normal, 
without  any  alleviation  of  the  constitutional  symptoms.  These  vary, 
those  of  the  gravest  toxemia  causing  death  in  less  than  two  days,  with 
great  swelKng  of  the  affected  parts,  so  much  so  as  to  cause  local  gan- 
grene. The  pulse  is  very  quick  and  feeble  and  all  the  constitutional 
symptoms  are  of  an  adynamic  character.  In  milder  cases  the  papules 
are  smaller  and  end  in  fighter  eschars  with  less  edema  or  impHcations 
of  the  deeper  parts. 


TUBERCULOSIS  1 67 

Intestinal  Form  of  Mycosis  Intestinalis.  In  these  cases  the  infec- 
tion usually  is  through  the  stomach  and  intestines,  and  results  from 
eating  the  flesh  or  drinking  the  milk  of  diseased  animals.  It  may 
follow  an  external  infection  if  the  germs  are  carried  through  the  mouth. 
The  disease  may  set  in  with  a  chill,  followed  by  vomiting,  diarrhea, 
moderate  fever,  and  pain  in  the  legs  and  back.  In  acute  cases  there 
are  dyspnea,  cyanosis,  great  anxiety  and  restlessness,  and  toward  the 
end  convulsions  or  spasms  of  the  muscles.  Hemorrhage  may  occur 
from  mucous  membranes.  Occasionally  there  are  on  the  skin  small 
phlegmonous  areas  or  petechiae.  The  spleen  is  enlarged,  the  blood  is 
dark,  and  remains  fluid  for  a  long  time  after  death.  Late  in  the  disease 
the  bacilli  may  be  found  in  the  blood. 

The  disease  is  found  in  operatives  who  have  had  to  handle  wool  of 
infected  animals  imported  from  Russia  or  South  America.  Though 
malignant  pustules  may  appear  on  the  surface,  yet  in  the  majority  of 
cases  there  is  no  external  manifestation,  but  instead  grave  symptoms, 
such  as  involvement  of  the  viscera,  the  lungs,  bronchi  and  the  brain, 
accompanied  first  by  much  pain  in  the  chest  and  cough,  and  in  the 
last  by  severe  cerebral  symptoms,  among  which  convulsions  are  com- 
mon. After  death  the  capillaries  in  the  brain  are  found  stuffed  with 
the  bacilli. 

In  the  pustular  surface  forms  the  mind  may  be  unaffected  to  the 
last,  and  the  patients  fail  to  manifest  any  anxiety  about  their  grave 
condition,  but  in  the  visceral  forms,  internal  pains,  both  in  the  chest 
and  in  the  back  and  limbs,  and  delirium  are  common. 

Treatment. — The  chief  indications  for  treatment  in  this  disease  are 
of  the  nature  of  prophylaxis,  which,  of  course,  must  vary  according  to 
the  country  or  other  circumstance  connected  with  its  prevalence. 
When  it  occurs  among  cattle  or  flocks  of  sheep  the  infected  animals 
must  at  once  be  quarantined.  In  cases  of  mahgnant  pustules  appear- 
ing on  the  surface,  the  seat  of  inoculation  should  be  cauterized  with  a 
hot  iron,  and  every  small  pustule  surrounding  it  should  be  injected 
with  a  small  drop  of  carbolic  acid,  as  in  the  treatment  of  boils.  In  the 
internal  form  of  intestinal  infection  nothing  can  be  done  but  stim- 
ulate the  patient  freely  with  alcohol  and  by  large  doses  of  quinin. 

TUBERCULOSIS 

We  begin  with  tuberculosis  because  it  affords  so  many  illustra- 
tions of  what  an  infective  disease  is.  Instead  of  attacking  one  or 
a  few  animal  species,  as  does  typhoid  fever,  no  warm-blooded  creature 
is  exempt  from  its  invasion,  and  it  even  occurs  among  some  of  the  cold- 


1 68  CLINICAL  MEDICINE 

blooded  kinds,  such  as  fishes  and  turtles.  It  prevails  less  among  wild 
than  among  domesticated  animals,  but  wild  animals  soon  succumb  to 
it  if  kept  in  captivity.  Herbivora  are  more  susceptible  to  it  than  car- 
nivora,  but  it  is  not  common  in  sheep  or  horses,  or  in  dogs  or  cats. 
Among  domesticated  birds,  such  as  fowls,  turkeys,  pigeons,  and 
peacocks,  it  prevails  in  a  special  form,  called  avian  tuberculosis,  but 
tuberculosis  is  most  virulent  among  cattle,  for  it  is  calculated  that  20 
per  cent,  of  all  cows  become  tuberculous.  Among  mankind,  it  is  well 
termed  "the  great  white  plague,"  for  it  is  estimated  that  it  destroys 
from  I  in  7  to  I  in  9  of  our  race,  but  in  civiHzed  countries,  both  in  Eu- 
rope and  America,  the  proportion  is  steadily  declining,  and  in  the  United 
States  it  causes  only  one-eighth  or  one-ninth  of  the  total  deaths. 

The  Bacillus  tuberculosis  was  first  identified  by  Koch  in  1882, 
but  tuberculosis  itself  is  the  most  ancient,  historically  known  to  us,  of 
all  infections  except  the  Bubonic  plague.  Tuberculosis  is  accurately 
described  by  Hippocrates  2300  years  ago,  and  is  also  referred  to  in 
Ebers'  Egyptian  papyrus,  1700  years  before  Hippocrates.  We,  there- 
fore, have  descriptions  of  it  for  4000  years.  Now,  as  the  life  period  of 
a  tubercle  bacillus  is  only  from  twenty  to  thirty  minutes,  counting 
only  the  aged  bacilli  (half  an  hour  old) ,  this  agent  has  passed  through 
7,420,000  generations  without  once  changing  its  character.  It  is  also 
claimed  that  it  is  mentioned  in  Babylonian  inscriptions  earHer  than 
those  in  Egypt, 

This  bacillus  grows  only  in  the  bodies  of  animals  affected  by  the 
disease.  It  can  be  cultivated  outside  the  body  in  specially  prepared 
media,  but  it  does  not  occur  naturally  in  any  particular  soil  or  locality. 
It  consists  of  slender  rods  varying  in  length  between  1.5  and  3.6  mm. 
It  has  no  spores,  but  in  certain  circumstances  it  may  grow  into  much 
longer  threads,  which  exhibit  true  branching.  This  shows  that  it  is 
a  higher  form  of  life  than  ordinary  bacteria,  and  that  it  is  alhed 
to  those  fungi  called  streptothrices. 

This  bacillus  can  be  recognized  by  its  taking  on  special  stains, 
whose  nature  the  reader  can  find  in  works  on  bacteriology.  These 
bacilli  contain  the  largest  proportion  of  fat  known  among  bacteria, 
and  also  a  form  of  wax. 

Miliary  Tuberculosis. — The  best  situations  in  which  to  study  the 
characters  and  properties  of  the  tubercle  bacillus  are  not  in  the  gross 
lesions  of  the  disease,  but  in  those  formations  called  miliary  tubercles. 
These  may  be  considered  as  the  beginning  of  the  changes  caused  by 
the  tubercle  bacillus  itself.  As  such  they  may  be  recognized  as  minute 
translucent  nodules,  sometimes  so  small  that  they  might  almost  be 


TUBERCXJLOSIS  1 69 

called  granules.  They  are  composed  at  first  of  a  roughly  concentric 
mass  of  cells  of  elongated  form,  with  long,  oval  nuclei,  continuous  with 
the  cells  of  the  surrounding  tissue.  Mingled  with  the  cells,  at  the  per- 
iphery of  the  nodule,  are  large  multinuclear  cells,  called  giant  cells.  The 
most  significant  fact,  however,  is  that  even  in  small  miliary  tubercles 
caseous  changes  at  their  center  may  already  have  begun.  These 
caseous  changes  are  the  leading  characteristics  of  tuberculous  lesions. 

Miliary  tubercles  may  have  their  origin  in  a  tuberculous  gland 
which  has  made  a  connection  with  a  vein  external  to  it,  so  as  to  dis- 
charge its  contents  into  the  venous  current  of  the  blood.  This  event 
is  a  truly  fatal  catastrophe,  leading  to  the  formation  of  miliary  tuber- 
cles, first  into  the  pulmonary  veins,  and  equally  in  the  thoracic  duct, 
and  from  thence  proceeding  to  every  organ  of  the  body,  producing 
general  miliary  tuberculosis.  We  will  now  see  what  the  poisons  of 
the  tubercle  bacillus  can  do.  A  general  fever,  not  high  in  degree,  but 
accompanied  with  great  nutritive  changes,  follows,  the  general  sjmip- 
toms  often  resembling  those  of  typhoid  fever.  In  some  cases,  however, 
the  lungs  are  most  involved  with  symptoms  of  universal  bronchitis. 
But  the  worst  and  most  frequent  changes  are  due  to  tuberculous  men- 
ingitis, both  of  the  base  of  the  brain  and  along  the  spinal  cord. 

The  varieties  of  tuberculosis  are  due  to  differences  between  the 
species  of  animals,  thus  the  avian  form  occurs  exclusively  in  birds.  On 
the  other  hand,  bovine  tuberculosis  is  so  closely  allied  to  the  human 
form  that  Koch's  contention,  that  bovine  tuberculosis  cannot  be 
transmitted  to  man,  is  undoubtedly  erroneous,  so  that  the  eating  of 
the  flesh  or  drinking  the  milk  of  tuberculous  cows  is  plainly  dangerous. 
On  the  whole,  therefore,  it  seems  probable  that  all  forms  of  tubercu- 
losis, whether  in  man  or  in  animals,  are  produced  by  the  same  organism, 
its  modifications  being  due  only  to  the  different  conditions  found  in 
different  animals. 

Immunity. — Being  a  chronic  disease,  it  is,  therefore,  not  self-limited, 
and  hence  it  is  doubtful  if  any  artificially  acquired  immunity  from  it 
can  be  expected.  Injections  of  various  forms  of  tuberculin  prepared 
from  the  dead  baciUi  were  hoped,  by  some,  to  modify  its  course  when 
given  in  fractional  doses.  At  one  time  it  was  expected  by  Koch  that 
his  tuberculin  might  prove  an  antidote  to  the  disease,  but  for  this  pur- 
pose it  proved  a  signal  failure,  nor  have  any  modifications  of  this 
treatment  subsequently  been  really  successful.  Injections  of  tuber- 
culin, however,  are  very  useful  for  purposes  of  diagnosis,  since  when 
any  body,  whether  human  or  animal,  has  become  infected,  a  specific 
febrile  reaction  which  lasts  for  a  number  of  hours  is  caused,  proving 


lyo  CLINICAL   MEDICINE 

the  existence  of  tuberculosis  in  the  body.  Our  only  recourse  against 
this  disease  has  been  to  increase  the  vital  resistance  of  the  system. 

The  Role  of  the  Tubercle  Bacillus. — It  becomes  of  great  interest, 
therefore,  to  know  how  the  tubercle  bacillus  itself  is  so  resistant  to 
any  influences  unfavorable  to  its  growth.  This  may  be  partly  ex- 
plained by  the  pecuHar  properties  of  the  bacillus  itself  in  the  changes 
which  it  occasions.  In  the  first  place,  as  just  stated,  this  bacillus  con- 
tains in  its  body  more  fat  than  any  other  micro-organism  and,  further, 
a  pecuhar  form  of  wax.  Both  the  fat  and  the  wax  have  been  shown  to 
be  poisonous,  and  this  may  account  for  that  remarkable  and  specific 
property,  which  is  characteristic  of  tuberculosis,  of  producing  an  al- 
teration in  its  immediate  neighborhood,  to  which  the  term  "caseous" 
has  been  applied.  The  first  effect  of  this  caseous  change  is  to  obHterate 
all  capillaries  supplying  the  part.  The  tubercle  bacilH,  therefore,  are 
at  the  beginning  protected  by  these  caseous  deposits  from  being 
reached  by  any  agent  in  the  blood.  In  time,  however,  the  bacilli 
themselves  suffer  from  this  deprivation  of  blood  and  degenerate. 
These  deposits  may  at  first  be  very  small,  but  afterward  may  coalesce 
into  considerable  masses.  Being  a  foreign  body,  it  gives  rise,  in  some 
cases,  to  an  inflammatory  action  about  the  caseous  deposit,  which  may 
fortunately  limit  the  local  spread  of  the  disease  by  the  formation  of 
fibrous  tissue.  But  this  fibrosis  is  not  general  in  its  occurrence;  in- 
stead of  that,  in  some  tissues,  especially  in  the  lungs,  the  inflammatory 
reaction  allows  fresh  deposits  of  the  bacilh  to  grow. 

The  essential  poison  of  this  bacillus  is  a  pecuhar  nucleic  acid,  which 
may  be  called  its  true  endotoxin.  It  contains  from  9  to  ii  per  cent,  of 
phosphorus.  The  most  striking  peculiarity  of  this  toxin  is  its  extra- 
ordinary resistance  to  heat  and  chemical  decomposition,  which  ex- 
plains the  great  difficulty  of  counteracting  it. 

Treatment. — We  have  no  specific  against  tuberculosis  either  in 
the  form  of  drugs  or  of  any  other  kind  of  remedy.  Another  important 
fact  is  that  tuberculosis  is  eminently  a  house  disease,  which  is  equiva- 
lent to  saying  that  it  is  a  disease  of  confinement  within  walls.  As 
above  stated,  wild  animals  do  not  usually  contract  tuberculosis  until 
they  are  kept  in  confinement,  which  renders  them  susceptible  to  it. 
But  as  all  civihzed  people  live  in  houses,  this  is  the  same  as  saying  that 
a  large  proportion  of  them  must  be  tuberculous,  especially  in  the  case 
of  children.  It  is  stated  that  in  Vienna  over  94  per  cent,  of  children 
are  infected.  The  prevalence  of  tuberculosis  cannot  be  measured  by 
those  who  present  the  cHnical  and  physical  symptoms  of  the  disease, 
because,  as  Birch-Hirschfeld  has  shown,  a  very  considerable  percentage 


TUBERCULOSIS  I71 

of  autopsies  prove  the  existence  of  former  tuberculous  lesions  of  the 
lungs  which  have  been  healed.  The  real  causes  of  such  spontaneous 
healing  are  worthy  of  further  study,  since  it  is  evident  that  such  re- 
covery must  be  due  to  the  individual  resistance  of  the  system  to  the 
infection.  The  great  problem  of  treatment  in  tuberculosis,  therefore, 
is  how  to  discover  and  promote  the  systemic  resistance  to  this  infection. 

Hence,  as  we  have  said,  our  chief  reliance  in  combating  the  ravages 
of  this  disease  must  be  by  combining  all  the  measures  which  tend  to 
increase  the  nutritive  powers  of  each  affected  individual.  First  and 
foremost  of  these  is  fresh  air,  which  is  not  easy  to  obtain  in  sufficient 
amount  within  doors.  On  that  account,  women,  from  their  domestic 
habits,  as  a  general  rule,  are  more  difficult  to  treat  than  men.  But 
the  reasons  for  fresh  air  being  effective  should  be  well  understood.  In 
the  first  place,  direct  sunHght  kills  the  tubercle  bacillus  in  seven 
minutes,  and  a  free  supply  of  fresh  air  greatly  lessens  its  \dtality. 

Another  important  factor  enters  into  the  cause  of  pulmonary  tuber- 
culosis. Lung  tissue,  owing  to  the  movements  of  respiration,  never  rests, 
and  hence  the  difficulty  of  heahng  any  injury  to  it.  If  a  sore  on  a  leg 
was  rubbed  up  and  down  from  1 8  to  30  times  a  minute  it  could  scarcely 
heal.  But  in  a  pulmonary  sore  we  soon  have  another  serious  compli- 
cation enter,  and  that  is  the  invasion  of  damaged  tissue  by  pyogenic 
cocci.  In  time  the  injury,  effected  by  this  disastrous  alliance  with 
pus-making  organisms,  may  quite  overshadow  the  original  tuber- 
cular infection,  rendering  patients  in  the  advanced  stages  of  phthisis 
virtually  cases  of  general  pyemia.  Now  it  happens  that  fresh  air 
is  as  inimic  to  the  pyogenic  cocci  producing  their  toxins  as  it  is 
to  the  tubercle  bacillus  itself,  and  these  two  reasons  should  be 
explained  to  patients  in  order  to  incite  them  to  be  unremitting  in 
their  efforts  to  live  an  outdoor  Kfe.  It  is  now  the  aim  of  physicians 
to  treat  pyemic  patients,  who  have  no  tuberculosis,  in  wards  erected 
on  the  roofs  of  hospitals,  where  the  supply  of  fresh  air  is  constant. 
The  great  success  which  has  attended  the  treatment  of  consump- 
tion in  various  sanatoria  is  largely  due  to  the  arrangements  made 
in  those  institutions  for  the  patients  to  breathe  fresh  air,  not  only 
by  day,  but  through  the  night.  Muscular  power  also  throughout  Hving 
nature  is  proportional  to  the  activity  of  respiration.  Huxley  calculated 
that  if  a  man  was  proportionately  as  strong  as  a  flea  he  could  move  the 
heavy  building  of  Newgate  Prison,  the  reason  being  that  an  insect 
breathes  from  every  part  of  its  body,  while  we  breathe  only  through 
the  local  mechanism  of  the  lungs.  A  free  supply  of  oxygen,  therefore, 
strengthens  every  muscular  organ  or  tissue,  such  as  the  heart,  the  mus- 


172  CLINICAL  MEDICINE 

cular  layer  of  the  arteries,  and  the  similar  muscular  supply  of  the 
bronchi.  It  also  increases  the  tone  of  the  stomach  and  of  the  intes- 
tines. 

This  explains  the  benefit  to  phthisical  patients  of  residence  in  a 
dry  atmosphere.  In  a  dry  atmosphere  the  interchange  between  the 
inhaled  and  the  residual  air  in  the  lungs  is  much  more  active  than  when 
the  outer  atmosphere  is  so  laden  with  moisture  that  there  is  but  little 
difference  between  it  and  the  air  in  the  lungs.  Other  things  being 
equal,  phthisical  patients  do  much  better  in  high  and  dry  regions,  as  in 
Colorado,  than  they  do  at  the  seaside. 

Next  to  fresh  air  comes  feeding.  All  patients  with  chronic  febrile 
complaints  need  to  assimilate  more  food  than  they  would  in  health, 
in  order  to  counteract  the  wasting  caused  by  fever  and  by  bacterial 
toxins.  Therefore  phthisical  patients  should  be  fed  at  least  six  times 
a  day,  but  it  should  be  remembered  that  food  is  food  only  when  it  is 
assimilated,  and  hence  every  effort  should  be  made  to  maintain  diges- 
tion at  its  highest  efficiency.  Injudicious  overloading  of  the  stomach 
may  be  as  harmful  as  underfeeding,  and  so  each  patient's  digestive 
capacity  should  be  carefully  noted. 

Where  practicable,  the  patients  should  not  take  their  dinner  alone, 
but  with  others,  because  it  is  well  recognized  that  pleasant  conversation 
is  a  great  help  to  both  relishing  and  digesting  the  meals,  and,  among 
other  things,  it  would  serve  to  divert  their  attention  from  their  own 
malady.  These  meals  should  be  varied  from  day  to  day,  as,  unHke  other 
animals,  man  insists  upon  a  variety  in  his  diet.  With  reference  to  the 
articles  of  food,  a  patient  with  phthisis  might  with  advantage  eat  like  a 
carnivorous  animal,  and  live  largely  on  meat,  particularly  beef.  After 
beef  comes  mutton.  Poultry  and  fish  are  relatively  of  less  value  to 
him,  except  as  they  afford  more  variety.  Milk  should  always  take  a 
leading  place,  because,  it  can  be  easily  taken  between  meals.  It 
should  be  remembered,  however,  that  milk,  as  such,  is  indigestible 
with  adults.  All  races,  therefore,  who  have  to  live  exclusively  on 
milk,  such  as  the  nomad  Tartars  and  Bedouins,  have  discovered  that 
the  stomach  must  be  spared  the  curdling  of  the  milk,  as  this  first  step 
of  digestion  uses  up  a  good  deal  of  the  pepsin  of  the  stomach.  They, 
therefore,  invariably  curdle  the  milk  by  fermentation,  either  by  the 
yeast  plant  or  with  the  Tartar  "kefir."  When  so  fermented,  milk  is 
the  most  perfect  food  in  the  world,  as  it  is  the  only  substance  out  of 
which  every  tissue  can  be  made,  illustrated  at  the  beginning  of  fife  by 
all  mammals.  The  only  deficiency  in  milk  is  its  small  proportion 
of  iron.     In  many  cases  milk  is  rendered  more  digestible  by  the  addition 


TUBERCULOSIS  1 73 

of  alkalis,  particularly  lime-water,  as  this  prevents  the  curd  being  too 
solid,  Uke  a  piece  of  cheese,  by  making  it  flaky.  The  usual  fault  in 
prescribing  lime-water  is  that  too  Httle  of  it  is  used.  It  should  always 
be  equal  parts  of  lime-water  and  milk — a  combination  which  will 
stay  down  in  conditions  of  nausea  when  nothing  else  will.  Eggs  are 
also  very  valuable  in  the  dietary,  but  in  my  opinion  they  are  often 
prescribed  in  too  great  numbers,  though  here  patients'  peculiarities 
should  be  observed,  for  with  some  people  eggs  are  Cjuite  indigestible. 
Butter  is  very  advantageous,  and  should  not  only  be  spread  on  bread, 
but  mixed  with  cereals  or  potatoes.  Vegetables  and  fruits  should  be 
given  freely,  according  to  the  patients'  powers  of  assimilation.  The 
patient  should  begin  by  taking  a  glass  of  milk,  which  may  be  either 
hot  or  cold  according  to  taste,  in  the  morning,  half  an  hour  before  ris- 
ing. No  patient  should  attempt  to  dress  without  first  taking  some 
food.  In  many  cases  2  or  4  teaspoonfuls  of  whisky  in  the  milk  may  then 
be  allowed.  Breakfast  at  7  to  8  a.  m.  should  consist  of  crusty  bread 
and  plenty  of  butter  with  a  digestible  cereal,  such  as  hominy,  as  this 
allows  of  considerable  quantities  of  milk  and  cream  being  taken.  This 
may  be  followed  by  two  eggs,  along  with  beefsteak  or  lamb  chop,  and 
with  a  good  supply  of  potato,  the  best  form  of  which  is  potato  stewed 
in  milk  and  cut  up  fine.  If  the  patient  is  at  all  troubled  with  con- 
stipation, this  meal  should  be  begun  with  fruit,  of  which  oranges  are 
the  best,  or  raw  apples,  if  these  are  well  borne.  About  10  a.  m.  the 
first  lunch  of  the  patient  may  be  taken,  consisting  of  a  glass  of  milk, 
with  loaf  gingerbread,  rather  than  any  other  cake,  the  ginger  in  it 
counteracting  the  acid  fermentation.  Some  may  take  a  raw  egg  in 
the  milk.  Dinner  at  i  o'clock  should  begin  with  soup,  and  then  meat 
with  potatoes  and  other  vegetables,  and  should  be  the  hearty  meal  of 
the  day,  according  to  rules  already  given.  For  dessert,  puddings  of  a 
simple  kind,  but  not  pies.  To  this  apple  sauce  or  baked  apples  with 
cream  may  be  added.  The  next  meal  should  be  a  lunch  at  4  o'clock. 
It  should  be  remembered,  however,  that  this  is  the  beginning,  in 
most  cases,  of  the  daily  febrile  rise,  and  hence  had  better  be  restricted 
to  milk  and  bread  and  butter.  The  evening  meal,  from  6  to  7  o'clock, 
may  be  more  hearty,  and  consists,  for  a  change,  of  poultry  or  fish,  of 
which  the  best  form  is  shredded  codfish  in  milk.  On  going  to  bed  the 
patient  should  always  take  much  the  same  meal  as  that  of  10  a.  m. 
But  another  important  detail  is  that  no  patient  should  be  allowed  to 
remain  wakeful  through  the  night  without  some  easily  digestible  food 
being  at  hand.     Water  may  be  taken  freely. 

Attention  is  not  often  sufficiently  directed  to  the  state  of  the  skin. 


174  CLINICAL  MEDICINE 

In  all  febrile  affections,  but  noticeably  in  phthisis,  the  first  effect  dur- 
ing prolonged  fevers  is  to  render  the  skin  dry,  but  this  dryness  is  sure 
to  be  followed  by  perspiration.  In  phthisis  this  perspiration  is  largely 
due  to  the  toxins  of  the  pyogenic  cocci,  and  hence  the  exhausting  night- 
sweats  of  this  disease,  which,  besides  being  weakening,  are  frequently  a 
cause  of  distress  to  the  patient.  Therefore  I  cannot  but  regard  as  a 
decided  loss  the  discontinuance  of  the  ancient  practice  of  inunction, 
or  anointing  the  body  with  oil.  It  should  be  remembered  that  the 
skin  cannot  absorb  water  as  such,  nor  most  other  fluids;  so  that  a 
person  may  sit  for  hours  without  any  harm  in  a  bath  abounding  with 
corrosive  subHmate  or  other  poisons.  Yet  everything  oily  can  be  made  to 
pass  through  the  skin  by  friction,  and  in  the  case  of  vegetable  oils,  like 
olive  oil,  may  do  so  with  decided  advantage  to  the  nutrition  of  the 
patient.  Febrile  processes,  especially  if  accompanied  by  subcutaneous 
edema,  lead  to  serious  derangement  of  the  cutaneous  structures,  as 
well  as  to  the  obliteration  of  the  mouths  of  the  sweat-glands.  Hence 
the  glossy  appearance  of  the  skin  when  the  extremities  are  edematous, 
the  scales  of  the  epidermis  becoming  tightly  superimposed  one  upon 
another.  Oily  inunctions  counteract  this,  and  so  I  am  in  the 
habit  of  ordering  the  body  to  be  rubbed  with  oil  in  all  dropsical  condi- 
tions, particularly  whenever  I  wish  the  skin  to  supplement  the  func- 
tions of  the  kidneys  by  proper  perspiration.  Night-sweats,  therefore, 
are  best  treated,  first,  by  sponging  the  surface  with  cold  water,  to  be 
followed  by  a  general  inunction  with  oil,  of  which  I  find  cocoanut  oil 
to  be  the  most  serviceable.  Half  a  dram  of  oil  of  cinnamon  may  be 
added  to  the  pint  of  cocoanut  oil,  to  give  a  grateful  odor  to  the  appli- 
cation. This  inunction,  performed  generally  once  or  twice  a  day, 
accompanied,  of  course,  by  active  friction,  greatly  improves  the  nutri- 
tion of  the  skin  and,  by  so  much,  the  well  being  of  the  patient.  As 
much  as  from  |  to  i  oz.  of  cocoanut  oil  can  thus  be  introduced  into 
the  system.  But  another  fact  is  often  strikingly  illustrated  by  this 
procedure,  namely,  reduction  of  the  temperature  from  i  to  2  degrees. 
Medicinal  Treatment. — The  primary  indication  in  the  treatment  of 
pulmonary  tuberculosis  is  to  cut  short  the  accompanying  bronchitis. 
In  proportion  to  the  extent  of  the  bronchitis  will  the  healing  powers  of 
the  system  be  interfered  with.  The  tubercle-laden  droplets  are  more 
or  less  widely  dispersed  through  the  bronchi  during  the  deep  inspira- 
tion which  precedes  the  act  of  coughing.  When  the  deposit  is  confined 
to  the  apex,  counterirritation  of  the  infraclavicular  space  is  of  great 
advantage.  This  may  be  secured  by  the  apphcation  of  several  coat- 
ings of  the  collodion  vesicant.     The  next  indication,  which  is  com- 


TUBERCULOSIS  1 75 

mon  to  all  forms  of  bronchitis,  is  to  make  the  bronchial  secretion  as 
fluid  as  possible.  This  can  be  done  much  more  effectively  by  the  ad- 
ministration of  oils  than  by  prescribing  the  ammonium  salts.  On 
that  account  I  regard  it  as  a  serious  disadvantage  that  cod-liver  oil 
has  gone  out  of  fashion  to  such  an  extent,  due  mainly  to  recent  fads 
among  the  physicians  of  sanatoria.  But  there  is  another  reason  for  the 
administration  of  cod-liver  oil.  Alany  years  ago  it  was  shown  by 
Andral  and  Simon,  and  has  been  frequently  confirmed  since,  that  cod- 
Hver  oil  increases  the  proportion  of  red  corpuscles  in  the  blood  much 
more  than  iron  or  any  other  medicinal  remedy.  Iron,  indeed,  is  con- 
tra-indicated in  treatment  of  phthisis  in  all  stages,  however  pro- 
nounced the  anemia,  due  to  the  fact  that  iron  is  not  assimilated  in  any 
febrile  condition,  but  rather  has  a  tendency  to  increase  the  fever.  In 
fact,  the  prognosis  in  many  cases  of  consumption  is  conditioned  by 
the  patient's  abihty  to  take  cod-Hver  oil.  Cod-hver  oil  should  always 
be  given  shortly  after  eating,  and,  if  at  first  a  patient's  stomach 
is  deranged  by  it,  it  should  be  begun  in  teaspoonful  doses,  gradually  in- 
creased to  a  tablespoonful.  Its  retention  by  the  stomach  is  promoted 
by  simultaneously  taking  an  acid  preparation  of  the  pepsin,  a  common 
prescription  of  mine  being  4  drams  of  lactic  acid  to  6  oz.  of  Fairchild's 
essence  of  pepsin,  the  dose  being  2  teaspoonfuls  with  each  dose  of  cod- 
liver  oil.  A  good  derivative  preparation  of  cod-hver  oil  is  called  hy- 
drolein,  which  is  often  better  borne  than  cod-liver  oil,  a  dose  being 
a  dessertspoonful.  When  a  patient,  as  is  so  commonly  the  case,  has  an 
aggravation  of  his  bronchitis,  he  should  remain  in  bed  two  or  three  days, 
omit  the  cod-hver  oil,  and  take  my  standard  remedy  for  bronchitis, 
namely,  the  emulsion  of  Hnseed  oil,  the  formula  for  which  will  be  given 
in  the  article  on  Bronchitis. 

The  question  often  arises  whether  we  have  any  medicinal  remedy 
for  tuberculosis,  the  answer  to  which  is  that  undoubtedly  the  creosote 
carbonate  or  the  guaiacol  carbonate  are  efficacious  for  that  purpose. 
The  creosote  carbonate  emulsion  will  be  mentioned  in  the  article  on 
the  Treatment  of  Lobar  Pneumonia.  It  ought  to  be  administered  in 
as  large  doses  as  the  patient  can  conveniently  take,  beginning  with  a 
tablespoonful  of  the  emulsion  (equal  to  1 5  gr.  of  the  carbonate)  an  hour 
after  meals  and  on  getting  to  bed ;  to  be  increased  afterward  as  freely 
as  possible.  The  effect  of  this  preparation,  both  on  the  bronchitis  and 
on  Hmiting  the  areas  of  pneumonic  infiltration,  is  undoubted.  Due 
to  similar  agents  is  the  benefit  derived  from  the  resinous  elements  sus- 
pended in  the  air  of  pine  forests,  the  primary  effect  of  which  is  to 
diminish  bronchitis,  and,  therefore,  ought  to  be  inhaled  by  the  patients 


176  CLINICAL   MEDICINE 

as  they  would  take  fresh  air.  The  Hst  of  other  medicinal  remedies  for 
these  patients  is  small.  When  there  is  profuse  secretion  the  old 
prescription  of  Williams  is  of  good  service,  which  consisted  of  small 
doses  (3  to  4  gr.)  of  potassium  iodid,  with  10  min.  of  dilute  nitric 
acid. 

Symptoms  of  Pulmonary  Tuberculosis. — Fever. — A  febrile  tempera- 
ture is  a  constant  occurrence  in  the  incipient  stages,  although,  not  being 
high,  it  is  often  unnoticed  by  the  patient  until  it  is  demonstrated  to 
him  by  use  of  the  thermometer.  Patients  with  a  temperature  of  102°  F. 
may  be  so  little  discommoded  by  it  that  they  continue  to  walk  about. 
The  patient,  therefore,  should  never  be  without  a  chnical  thermometer. 
In  the  early  stages  the  temperature  is  more  accurately  registered  in 
the  rectum,  but  by  consecutive  observations  it  may,  however,  be 
pretty  well  judged  when  taken  under  the  tongue.  But  the  patient 
should  not  have  recently  taken  either  a  hot  or  a  cold  drink,  for  it  may 
be  too  low  in  one  case,  and  too  high  in  the  other.  The  temperature 
is  always  raised  by  exercise.  In  phthisis,  the  morning  temperature 
may  be  subnormal,  but  it  rises  in  the  afternoon  about  3  o'clock.  It  is 
curious  how  often  this  fever  may  continue  for  days,  at  the  beginning, 
without  the  patient  being  aware  that  there  is  anything  wrong  with 
him.  But  should  a  febrile  temperature  of  100°  F.  in  the  afternoon  con- 
tinue for  many  weeks,  he  should  be  carefully  examined  for  pulmonary 
trouble;  the  only  other  causes  of  continuous  fever  being  due  to  the 
presence  of  a  hidden  source  of  suppuration  or  to  chronic  rheumatism. 
There  can  be  no  doubt  that  this  fever  is  produced  in  the  early  stages 
solely  by  the  tubercle  bacillus.  Afterward,  when  the  pyogenic  cocci 
complicate  the  affection,  the  minimum  and  maximum  temperature  for 
the  twenty-four  hours  vary  greatly,  in  what  may  be  called  the  hectic 
stage  of  the  disease,  ranging  from  99°  F.  in  the  morning  to  104°  F.  in 
the  afternoon.  Any  degree  of  marked  fever  not  due  to  compHcations 
indicates  activity  in  the  pulmonary  lesions.  Aspiration  pneumonia 
not  uncommonly  follows  hemoptysis,  with  a  higher  range  of  tempera- 
ture for  an  uncertain  number  of  days.  In  acute  mihary  tuberculosis 
the  temperature  is  continuously  high,  with  but  sHght  morning  remis- 
sions, so  that  it  may  be  mistaken  for  typhoid  fever.  In  fibroid  tuber- 
culosis, on  the  other  hand,  the  temperature  may  be  quite  low. 

The  Pulse.— The  state  of  the  pulse  should  always  be  noted,  for 
increased  frequency  is  a  constant  symptom  from  beginning  to  end. 
At  the  very  beginning  the  pulse  may  run  from  90  to  100  beats,  even 
though  the  patient  is  resting  in  bed.  From  the  commencement  the 
pulse  is  increased  in  frequency  by  slight   causes   which  would  not 


TUBERCULOSIS  1 77 

affect  it  in  health,  such  as  mental  excitement,  or  by  slight  physical 
exercise,  or  even  a  full  meal,  when  the  range  may  be  between  90  to 
120  beats,  though  this  tachycardia  is  seldom  noticed  by  the  patient 
himself.  This  chronic  frequency  of  the  pulse  must  be  due  to  the  spe- 
cific action  of  tuberculosis.  In  addition  to  the  frequency  of  the  pulse, 
the  tension  is  low. 

Next  to  the  symptoms  of  the  pulse  we  would  rate  emaciation. 
Emaciation,  as  we  have  stated,  is  not  only  loss  of  fat,  but  loss  of  bulk 
in  every  tissue  of  the  body  except  one,  that  one  being  the  nervous 
system.  In  advanced  stages  of  phthisis  this  is  particularly  noticeable 
in  the  bones,  the  shafts  of  the  long  bones  being  ver}^  small  and  thin. 
The  muscular  tissues  are  equally  affected.  Young  persons  lose  weight 
more  rapidly  than  older  ones.  In  the  early  stage  the  patient  may  note 
that  he  weighs  at  least  10  pounds  less  than  his  normal  weight.  Along 
with  loss  of  weight  there  is  apt  to  be  loss  of  strength,  which  may 
be  out  of  all  proportion  to  the  discoverable  lesion.  The  patient  may 
think  that  he  has  as  much  muscular  strength  as  ever  for  a  single  act, 
but  is,  however,  unable  to  sustain  it  for  any  length  of  time. 

In  appearance  the  patient  may  not  at  first  show  that  he  is  anemic, 
but  this  mistake  is  natural,  because  the  mucous  membranes  of  the 
lips,  for  example,  retain  their  red  color.  An  inspection  of  h^s  eyes, 
liowever,  will  show  that  the  eyeball  is  too  clearly  seen  through  the 
conjunctiva  and,  therefore,  has  a  glassy  appearance.  Neither  the 
red  cells  nor  the  leukocytes  are  much  affected  at  the  beginning. 
Among  digestive  disorders,  nausea  is  the  earliest  and  most  constant, 
being  present  in  some  cases  before  any  other  sign.  Vomiting  comes 
afterward,  and  is  very  common  to  occur  after  prolonged  coughing, 
particularly  from  raising  the  accumulations  in  a  cavity. 

Cough,  in  the  earliest  stages  of  phthisis,  may  be  one  of  the  symptoms 
which  the  patient  or  his  friends  first  notice.  This  cough  at  first  is 
purely  irritant  and  not  expectorant,  and  is  caused,  as  we  have  already 
explained,  by  the  irritation  of  pleuritic  adhesions  about  the  apex.  It 
is,  therefore,  of  a  dry,  hacking  character.  After  a  time  it  becomes 
mixed  with  the  sounds  of  an  expectorant  cough,  especially  on  rising  in 
the  morning,  when  the  patient  may  bring  up  small  quantities  of  viscid 
mucus.  He  might  be  asked  at  this  time  whether  he  complains  of 
slight  rheumatic  pains  about  his  shoulders. 

Examination  of  Chest. — It  is  now  high  time   that  the  physician 

should  make  a  careful  physical  examination   of    the  chest  by  the 

methods  of  inspection,  percussion,  and  auscultation.      In  some  cases 

a  dry  cough,  with  fever  and  rapid  pulse,  progresses  until  the  voice  be- 

12 


178  CLINICAL  MEDICINE 

comes  changed  or  very  hoarse,  and  finally  suppressed.  Inspection 
of  the  throat  shows  that  it  is  universally  injected,  and  in  many 
cases  very  intolerant  of  the  laryngoscopic  mirror,  the  shghtest  touch 
of  which  on  the  palate  causes  vomiting.  These  symptoms  are  often 
caused  by  enlarged  and  infiltrated  bronchial  glands  at  the  root  of  the 
lungs,  which  press  upon  the  vagus  or  pneumogastric  nerve.  I  have 
several  times  predicted  that  all  these  symptoms  would,  in  due  course, 
disappear,  owing  to  the  softening  of  the  glands,  causing  the  pressure 
on  the  vagus  to  lessen. 

As  the  disease  progresses  more  and  more  of  the  pulmonary  tissues 
become  consolidated,  revealed  by  increased  area  of  dulness  on  percus- 
sion, and  commonly  by  increased  vocal  fremitus.  On  auscultation  the 
inspiratory  sound,  which,  at  first,  has  the  characteristics  of  harsh  or 
peurile  breathing,  becomes  louder  and  high  pitched,  while  the  expira- 
tion becomes  prolonged,  a  very  important  sign,  rarely  found  in  health. 
This,  in  time,  increases  to  true  bronchial  breathing,  which  is  charac- 
terized by  its  high  pitch  and  by  its  tubular  quahty,  and  by  a  pause 
between  the  end  of  inspiration,  and  the  beginning  of  expiration,  which 
sounds,  in  health,  follow  each  other  directly.  Along  with  this,  the 
voice  is  transmitted  too  clearly  to  the  ear,  and,  if  the  consolidation  is 
extensive,  the  voice  sound  is  called  bronchophony.  At  this  time  also 
it  is  well  to  Hsten  to  the  sound  produced  by  a  whisper,  as  in  counting. 
On  inspection  the  infraclavicular  space  is  depressed,  and  the  move- 
ments of  breathing  are  diminished,  best  noted  by  looking  down  from 
behind.  As  softening  commences,  bronchitis,  in  the  affected  area,  is 
accompanied  by  rales.  These  often  resemble  the  friction  sounds  pro- 
duced by  pleurisy,  but  can  be  distinguished  from  them  by  having  the 
patient  cough,  which,  by  removing  the  bronchial  secretions,  changes  the 
sound,  while  this  does  not  occur  in  the  continuous  rubbing  sound  of 
pleurisy.  When  a  cavity  is  formed  the  bronchial  breathing  is  substi- 
tuted by  cavernous  breathing,  which  is  an  exaggeration  of  bronchial 
breathing,  with  a  greater  interval  between  the  end  of  inspiration  and 
the  beginning  of  expiration,  and  usually  the  expiration  is  of  much  lower 
pitch  than  the  inspiration.  If  the  cavity  is  superficial,  the  voice, 
whether  ordinary  or  whispered,  is  transmitted  to  the  ear  so  clearly 
that  it  is  called  pectoriloquy.  By  this  time  the  expectoration  has 
become  very  profuse  and  purulent.  With  further  progress  of  the  dis- 
ease the  sounds  become  very  numerous  and  varied,  cavernous  near  the 
cavity  and  bronchial  in  its  neighborhood,  and  then  with  fine  and  coarse 
bronchial  rales  beyond.  Meanwhile,  the  fever  becomes  more  continu- 
ous, emaciation  progresses,  and  now  another  complication  may  be 


TUBERCULOSIS  179 

added,  namely,  tuberculous  ulceration  of  the  intestines,  usually  caused 
by  the  patient  swallowing  the  infected  sputum.  Patients,  therefore, 
should  be  told  not  do  do  that,  though  this  may  occur  also  during 
sleep.  At  this  period  night-sweats  become  very  profuse,  the  larynx 
often  becomes  involved  from  infected  expectoration,  and  aphthous 
sores  then  appear  all  through  the  mouth  and  throat,  rendering  swallow- 
ing painful,  while  the  ulceration  of  the  intestines  leads  to  a  loose  but 
exhausting  diarrhea. 

I  have  often  diminished  the  painful  cough  accompanying  cavities 
by  firmly  strapping  the  ribs  over  the  cavity  with  adhesive  plaster, 
thereby  diminishing  the  pull  on  the  walls  of  the  cavity  by  its  extensive 
pleuritic  adhesions. 

Fibroid  Phthisis. — A  very  important,  if  not  essential,  procedure 
for  diagnosis  in  the  early  states  of  phthisis  is  an  examination  of  the 
sputum,  by  the  microscope,  for  the  presence  in  it  of  tubercle  bacilH. 
This  should  be  done  repeatedly,  because  the  bacilK  may  not  appear 
at  first,  but  only  after  repeated  examination.  The  best  sputum 
to  examine  is  that  which  is  expectorated  first,  on  rising  in  the  morn- 
ing. It  should  be  noted,  however,  that  it  may  be  difi&cult  to  find 
the  bacilli  in  the  chronic  form  of  phthisis,  called  fibroid  phthisis,  w^hich 
condition  may  as  well  be  described  here. 

This  disease  is  chronic,  lasting  from  ten  to  twenty  or  more  years. 
Its  chief  s3anptoms  are  paroxysmal  cough,  most  marked  in  the  morn- 
ing, with  dyspnea  on  exertion.  The  expectoration  may  be  profuse 
and  purulent,  and  as  the  bronchi  are  frequently  dilated  in  this  condi- 
tion, the  retained  secretion  in  them  may  be  quite  fetid,  at  other  times 
the  secretion  is  mucoid  and  contains  small  calcareous  concretions. 
There  is  rarely  fever,  but  the  physical  signs  are  very  characteristic. 
The  chest  is  sunken  and  the  shoulder  lower  on  the  affected  side. 
The  heart  is  often  drawn  over  and  displaced,  so  that,  if  the  left  lung 
be  involved,  the  area  of  the  cardiac  pulsation  maybe  visible  in  the  third, 
fourth,  and  fifth  interspaces.  Where  the  right  lung  is  involved,  I 
have  known  the  heart-beat  to  be  pronounced  in  the  right  armpit. 
Dropsy  may  also  be  present  from  failure  of  the  right  heart. 

Tuberculous  Laryngitis. — One  of  the  most  distressing  complica- 
tions, or  accompaniments,  of  pulmonary  phthisis  is  tuberculous  laryn- 
gitis. The  prognosis  of  phthisis  is  very  unfavorable  if  tuberculous 
laryngitis  sets  in  early.  Usually  it  comes  late,  and  is  then  due  to  the 
lodgment  of  the  bacilli  from  the  sputum  in  the  mucous  membrane 
of  the  larynx,  and  hence  begins  on  the  side  of  the  larynx  corresponding 
to  the  aflected  lung,  forming  shallow  ulcers  covered  with  a  grayish 


l8o  CLINICAL  MEDICINE 

exudation,  especially  on  the  arytenoid.  These  ulcers  may  erode  the 
true  chords  and  finally  destroy  them.  Even  the  epiglottis  may  be 
entirely  destroyed. 

Symptoms. — The  first  indication  is  sHght  huskiness  of  the  voice, 
which,  as  the  ulceration  proceeds,  causes,  first,  hoarseness  and  then 
complete  aphonia.  But  the  worst  and  most  painful  development  is 
when  the  epiglottis  is  involved  or  possibly  destroyed,  when  every 
attempt  to  take  food  brings  on  distressing  paroxysms  of  suffocative 
cough. 

Treatment. — The  voice  should  not  be  used.  Local  applications 
(morphin,  i  part;  finely  powdered  starch,  lo  parts)  every  two  or  three 
hours  often  give  relief. 

The  ulcers  should  be  sprayed  with  a  solution  of  tannic  acid,  2  gr. 
to  the  ounce.  A  4  per  cent,  solution  of  cocain  may  be  used  to  enable 
a  patient  to  suck  milk  from  a  vessel  placed  on  the  floor  while  his  head 
hangs  over  the  edge  of  the  bed. 

Tuberculous  Lymphatic  Glands. — For  a  long  time  scrofula  and 
tuberculosis  were  considered  as  separate  diseases.  The  term  "scrofula" 
was  then  used  to  denote  inflammation  and  chronic  swelling  of  the 
lymphatic  glands,  especially  about  the  neck.  Since  the  discovery  of 
the  tubercle  bacillus  the  term  "scrofula"  is  no  longer  used,  because 
the  ubiquitous  tubercle  bacillus  was  found  to  be  the  cause  of  all  the 
supposed  scrofulous  gland  diseases,  with  the  tendency,  as  everywhere 
else,  to  the  specific  caseous  changes  caused  by  tuberculosis.  There 
can  be  no  doubt,  however,  that  the  lymphatic  glands  form  the  first  Hne 
of  defense  of  the  body  against  the  infections.  Nowhere  is  this  so  well 
demonstrated  as  in  those  cases  where  these  glands  are  invaded  by  the 
tubercle  bacillus,  because  almost  invariably  we  find  that  the  virulence 
of  this  bacillus  is  greatly  lessened  after  it  enters  a  lymphatic  gland; 
in  the  majority  of  instances  of  tuberculous  lymphatic  glands,  in  the 
neck,  for  example,  the  disease  does  not  become  general,  and  is  much 
milder  in  its  course,  so  that  most  of  these  patients  recover  in  a  way 
that  shows  how  truly  this  formidable  infection  is  arrested.  Experi- 
ments by  R.  Loving  and  Lingard  are  very  conclusive,  that  the  viru- 
lence of  the  tubercle  bacillus  is  much  lessened  when  it  produces  the 
characteristic  changes  in  the  lymphatic  glands. 

The  starting-point  in  the  process  of  this  adenitis  begins  on 
the  mucous  membrane  of  the  skin,  thus  ulcerations  in  the  nose  or 
chronic  otitis  or  eczema  of  the  scalp  may  be  the  beginning  of  inflam- 
mation of  the  lymphatic  glands  which  he  nearest  to  the  veins  or  lym- 
phatics proceeding  from  those  parts.      Similarly,  such  lesions  may  be 


TUBERCULOSIS  l8l 

the  track  for  the  infection  by  the  tubercle  bacillus,  for  often  we  find 
that  so-called  scrofulous  glands  have  undoubtedly  been  preceded  by 
chronic  catarrh  of  the  throat  or  nose,  or  like  inflammations  of  the 
scalp. 

Symptoms. — The  first  evidences  of  this  infection  in  the  neck,  for 
example,  are  small  enlargements  of  the  lymphatic  glands,  which  gradu- 
ally grow  to  form  painless  discrete  tumors,  over  which  the  skin  at 
first  is  easily  movable.  These  tumors  may  spontaneously  subside 
without  suppuration,  while  in  other  patients  they  progress  until  fluc- 
tuation shows  that  suppuration  has  taken  place  in  the  gland.  Like 
suppuration  elsewhere,  the  pus  must  be  let  out,  for  if  it  is  left  to  burst 
externally  it  leaves  an  ugly  scar,  due  to  its  slow  process  of  healing. 
Sir  James  Paget  prescribed  a  mode  of  preventing  such  a  scar,  which  in 
after-life  might  greatly  disfigure  the  neck,  and  be  especially  objection- 
able in  women.  His  procedure  was  to  make  a  minute  opening  through 
which  he  introduced  two  or  three  steriHzed  horse-hairs  and  left  them 
there  to  drain  the  abscess,  with  the  result  that  the  skin  was  saved 
from  ulceration.  I  have  frequently  adopted  this  procedure,  with  great 
success,  in  preventing  all  scars  there  in  after-Hfe.  Though  constitu- 
tional infection  is  not  common,  yet  neglected  scrofulous  tumors 
may  in  time  develop  into  pulmonary  phthisis.  In  such  cases  the 
track  of  infection  is  by  implication  of  the  glands  at  the  root  of  the 
lungs.  A  patient,  therefore,  with  chronically  enlarged  glands  in  the 
neck  should  adopt  the  same  measures  of  treatment  prescribed  for 
pulmonary  tuberculosis. 

Tuberculous  Meningitis. — This  sad  affection  occurs  chiefly  in 
children  between  the  second  and  seventh  years.  When  its  nature  is 
suspected  a  tubercular  focus  is  to  be  looked  for,  either  at  the  apices  of 
the  lungs  or  in  some  tubercular  disease  of  bones  and  joints.  But  at 
other  times  no  such  discovery  can  be  made,  because  the  disease 
may  begin  in  tuberculous  peritonitis  when  its  original  seat  may  be  in 
the  mesenteric  glands. 

It  has  been  supposed  that  drinking  the  milk  of  tuberculous  cows 
or  even  of  eating  the  beef  of  such  animals  may  first  infect  the  ali- 
mentary canal,  and  then  extend  to  the  bronchial  glands,  and,  finally, 
to  the  membranes  at  the  base  of  the  brain. 

In  the  majority  of  cases  tubercular  basal  meningitis  is  the  chief 
lesion  found,  occasionally  with  involvement  of  the  cervical  meninges 
as  well. 

The  onset  is  usually  gradual,  marked  by  loss  of  appetite,  emaciation, 
and  irritability.     One  of  the  earliest  and  most  significant  symptoms 


1 82  CLINICAL   MEDICINE 

is  an  irregularity  of  the  pulse.  After  a  time  febrile  symptoms  become 
more  pronounced,  though  the  temperature  is  rarely  high. 

But  an  ominous  sign  is  the  supervention  of  causeless  vomiting. 
Soon  afterward  headache  is  complained  of,  coming  on  in  paroxysms 
which  cause  the  child  to  cry  out.  The  pupils  often  at  the  beginning 
are  contracted,  but  ere  long  definite  symptoms  show  themselves  by 
irregular  contraction,  and  in  the  later  stages  they  may  be  dilated. 
Disturbance  of  the  muscles  which  move  the  eyeball,  and  which  are 
innervated  by  the  third  and  sixth  nerves,  causing  the  supervention  of 
squint,  are  almost  pathognomonic.  Meantime  the  bowels  are  obsti- 
nately constipated,  and,  different  from  most  other  affections,  the 
abdominal  walls  are  retracted.  Muscular  symptoms  then  set  in, 
consisting  first  of  twitchings  or  of  locaUzed  monoplegias,  occasionally 
with  retraction  of  the  head.  Ultimately,  with  the  progress  of  the  dis- 
ease, effusion  occurs  in  the  ventricles,  producing  symptoms  of  brain 
pressure  with  coma. 

This  disease  is  often  characterized  by  deceptive  remissions,  which, 
however,  should  never  deceive  the  physician,  for  the  prognosis  of  tuber- 
cular meningitis  is  always  bad.  The  anatomic  findings  after  -death 
explain  this  fact,  for  the  basal  structures  of  the.  brain  may  be  coated 
with  a  seropurulent  exudate  which  follows  the  course  of  the  chief 
brain  arteries,  but  rarely  extends  to  the  superior  cerebral  convolutions. 

One  of  the  most  trustworthy  procedures  for  diagnosis  is  by  exam- 
ining the  cerebrospinal  fluid,  obtained  by  lumbar  puncture,  which 
often  settles  the  diagnosis  at  once,  because  in  the  turbid  fluid  so  ob- 
tained the  characteristic  signs  of  tubercular  meningitis,  in  distinction 
from  other  forms  of  meningitis,  are  found,  including  the  actual  pres- 
ence of  tubercle  bacilH. 

All  treatment  is  practically  unavaihng  in  this  malady,  and  our  chief 
efforts  should  be  to  alleviate  the  symptoms  by  the  administration  of 
coal-tar  derivatives,  such  as  phenacetin,  along  with  chloral.  lodids 
are  often  administered,  but  are  unavailing. 

Lupus,  or  Tuberculosis  of  the  Skin. — Tuberculosis  of  the  skin 
occurs  most  commonly  in  the  form  called  lupus.  The  affected  areas 
may  be  either  circumscribed  or  diffuse.  This  infection  of  the  skin 
always  comes  from  without  and  has  no  connection  with  tuberculosis 
of  the  inner  organs.  The  lesions  occur  either  in  the  form  of  pale 
brownish  or  bluish  non-vascularized  nodules,  sharply  marked  off 
from  the  adjacent  normal  skin,  or  as  spreading  hyperemic  areas  ele- 
vated above  the  surrounding  surface,  and  showing  their  brown  pig- 
mentation  only  when  the  blood-vessels   are  emptied  by  pressure. 


TUBERCULOSIS  1 83 

Their  consequent  ulcerations  may  appear  on  such  exposed  surfaces 
as  the  nose  and  cheeks.  These  ulcers  are  extraordinarily  difficult 
to  heal,  for  they  reappear  after  having  been  seemingly  cured.  These 
ulcerations,  besides  being  so  obstinate,  often  cause  unsightly  scars 
which  greatly  disfigure  the  face.  Their  essentially  tuberculous  nature 
is  demonstrated  by  finding  the  tubercle  bacilH  either  in  situ  or  in  the 
discharges  from  the  ulcers. 

Treatment. — Being  a  tubercular  disease,  constitutional  treatment 
the  same  as  we  would  use  for  tuberculosis  in  general  is  always  indi- 
cated, and  for  this  purpose  nothing  can  be  better  than  a  free  and  con- 
tinuous use  of  cod-liver  oil.  To  make  the  cod-Hver  oil  more  adaptable 
to  the  stomach,  we  should  simultaneously  administer  acidulated  pep- 
sin, as  we  have  mentioned  previously,  of  4  drams  of  lactic  acid  to  6  oz. 
of  Fairchild's  essence  of  pepsin ;  dose,  2  teaspoonfuls  in  water  after  meals 
with  the  cod-hver  oil.  Dr.  T.  McCall  Anderson  highly  recommends 
phosphorus  in  this  complaint,  which  may  be  given  in  15-gr.  doses  of 
glycerophosphate  of  soda  and  of  hme  three  times  a  day,  just  before 
eating  or  in  the  official  syrup  of  the  hypophosphites,  the  dose  of 
which  is  2  teaspoonfuls  in  water  after  meals. 

The  local  treatment  is  by  the  use  of  more  or  less  caustic  appHca- 
tions,  of  which  the  best  is  Hebra's  ointment,  composed  of  arsenici  albi 
10  gr.,  cinnabaris  factitiae  \  dram,  unguenti  rosati  |  oz.  This  apph- 
cation  only  destroys  the  morbid  structures  and  not  the  healthy  skin, 
which  is  not  even  excoriated  by  it.  Strips  of  linen  of  a  finger's 
breadth,  spread  thickly  with  the  paste,  are  first  apphed,  a  piece  of 
wadding  is  then  placed  over  them  and  kept  firmly  apphed  by  means 
of  strapping  and  a  broad  bandage.  In  twenty-four  hours  the  dressing 
is  renewed  after  first  thoroughly  cleansing  the  surface.  After  two  or 
three  apphcations  the  lupus  nodules  will  be  charred  and  of  a  brownish- 
black  color.  In  a  few  hours  after  the  removal  of  the  paste,  pain  and 
swelhng  are  gone,  and  in  a  few  days  eschars  separate,  when  the  ulcers 
speedily  cicatrize,  leaving  very  little  disfigurement. 

These  facts  show  that  the  tubercle  bacillus  has  great  vitahty,  for, 
although  not  alhed  with  any  other  infection  and  situated  so  super- 
ficially on  the  skin,  it  is  yet  by  no  means  easily  destroyed,  requiring  all 
of  the  powers  of  nutrition  of  the  body  to  be  called  upon  to  resist  its 
invasion,  besides  resisting  the  local  appHcation  of  strong  caustics. 

Tuberculosis  of  Bones. — Tuberculous  disease  of  bones  is  a  common 
affection,  particularly  in  the  young.  We  have  treated  elsewhere  of 
tuberculous  infection  of  the  spinal  column  with  consequent  destruc- 
tion of  the  vertebras,  and  of  the  formation  of  abscesses,  which  as  in 


184  CLINICAL   MEDICINE 

psoas  abscess  may  point  at  a  long  distance  from  their  original  tuber- 
culous focus  in  the  bones.  But  tuberculosis  may  infect  many  other 
joints  of  the  body,  such  as  the  hip-joint,  with  such  destruction  of  the 
joint  cavity  that  the  bone  is  dislocated  and  may  remain  outside  and 
above  the  acetabulum,  causing  shortening  of  the  leg.  The  knee-joint 
may  also  be  affected,  accompanied  with  considerable  effusion  within  the 
synovial  capsules;  this'  was  formerly  called  white  swelling  of  the 
knee  and  is  often  characterized  by  erosion  of  the  cartilages  and  dis- 
ease of  all  the  bony  structures  of  the  joints.  It  is  also  not  uncommon 
in  the  ankle-  and  wrist-joints,  causing  special  deformities  and  fettering 
of  the  movements  of  those  structures,  which  have  to  be  treated  accord- 
ing to  their  own  indications. 

One  fact  may  be  noted,  which  is,  that  tuberculous  disease  of  bones 
does  not  often  lead  to  general  systemic  tuberculosis,  and  but  rarely 
leads  to  pulmonary  phthisis. 

LEPROSY 

Among  the  chronic  infectious  diseases,  leprosy  is  of  great  though 
of  unknown  antiquity.  It  is  said  that  it  is  clearly  described  in  Egyp- 
tian papyri  thirty  centuries  before  the  Christian  era.  It  is  very  fully 
described  in  the  Bible,  especially  in  the  book  of  Leviticus,  where  the 
remarkable  statement  is  made  of  its  clinging  to  the  walls  of  houses, 
so  that  it  was  enjoined  to  take  the  plaster  down  and  burn  it.  Consid- 
ering its  affinity  to  tuberculosis,  which  also  is  very  prone  to  settle  upon 
walls,  the  ancient  mention  of  this  hygienic  measure  is  interesting. 
Its  epidemic  prevalence  is  nowhere  referred  to,  though  in  the  Middle 
Ages  it  must  have  prevailed  to  a  far  greater  extent  than  now,  and  yet 
at  present  it  is  found  in  every  part  of  the  world,  in  Russia,  in  Norway, 
in  Iceland  and  in  Hindustan,  in  China,  and  the  Philippines.  In 
America,  it  has  undoubtedly  been  imported  from  Europe,  and  lately 
in  California  by  the  Chinese.  In  the  United  States  its  greatest  prev- 
alence has  been  in  restricted  areas  of  Louisiana.  The  discovery  of 
the  lepra  bacillus  by  the  Norwegian  Hansen,  of  Bergen,  might  have  been 
supposed  to  throw  much  light  upon  the  nature  and  propagation  of  the 
disease,  but  instead  these  problems  have  been  hardly  advanced  at  all. 

The  organism  belongs  to  the  fission  fungi,  and  is  non-motile.  Its 
length  is  half  to  three-quarters  the  diameter  of  a  human  red  blood-cor- 
puscle, and  its  breadth  about  one-fifth  of  its  length.  Spore-like  bodies 
may  be  seen  in  the  bacilli  by  high-power  microscopes. 

We  are  wholly  uncertain  about  its  modes  of  communication  from 
person  to  person,  although  this  must  be  accepted,  because  it  is  a 


LEPROSY  185 

human  disease  and  cannot  be  given  to  animals.  Its  bacilli  are  found 
in  enormous  numbers  in  leprous  nodules,  and  equally  so  in  such  secre- 
tions as  the  saliva,  and  still  more  in  the  nasal  passages.  From  their 
abundance  it  would  seem  as  if  infection  by  the  lepra  bacilli  should  be 
as  common  as  in  the  case  of  tuberculosis.  It  is  curious  that  the  lepra 
bacilli  and  the  tubercle  bacilli  are  often  mentioned  together  by  writers 
as  if  they  were  allied  forms,  but  it  is  very  fortunate  for  mankind  that 
they  have  no  resemblance  to  each  other  in  their  most  important  fea- 
tures. The  lepra  bacilli  can  grow  only  in  human  bodies,  and  evidently 
do  not  easily  lodge  there,  while  tuberculosis,  besides  its  ravages  in  the 
human  species,  attacks  nearly  every  animal  of  the  vertebrate  series. 
To  this  day  we  are  doubtful  about  its  ways  of  dissemination.  It  is 
certainly  not  hereditary,  and  persons  may  be  in  close  association  for 
years  with  leprous  patients  without  contracting  the  disease,  nor  has  it 
any  relation  with  either  food  or  drink. 

Symptoms. — Leprosy  is  always  one  disease,  though  it  may  assume 
different  external  manifestations.  The  first  is  called  the  smooth  or 
anesthetic  variety,  the  skin  showing  external  white  patches  similar  to 
leukoderma.  A  case  which  I  saw  in  Syria  would  recall  the  language 
used  about  leprosy  in  the  Bible,  in  which  the  skin  is  said  to  have  been 
as  white  as  snow.  After  various  pains  in  the  affected  area  it  becomes 
quite  anesthetic,  so  that  pins  may  be  pushed  through  the  skin  without 
pain.  In  this  form  the  nervous  trunks  leading  to  the  affected  areas 
are  thickened,  enlarged,  and  beaded.  The  other  or  nodular  form  is 
usually  preceded  by  a  macular  eruption,  and  in  both  forms  bullae 
which  may  be  quite  extensive  may  develop,  soon  to  break  and  to 
leave  deep  ulcerations.  The  parts  first  affected  are  usually  the  ears, 
nose,  and  malar  regions  of  the  face,  producing  great  disfiguration  of 
the  countenance,  but  the  nodules  may  subsequently  appear  on  the 
trunk,  and  then  on  the  extremities.  The  most  characteristic  lesions, 
however,  especially  of  the  later  stages  of  the  disease,  involve  the  fingers 
and  toes,  with  such  deep  ulcerations  resulting,  that  the  phalanges  drop 
off  one  by  one.  On  mucous  membranes  the  eruption  is  very  similar  in 
its  course,  and  ulcerations  may  even  involve  the  epiglottis,  the  larynx, 
and  the  vocal  chords.  It  is  pecuHar,  however,  how  extremely  chronic 
may  be  the  course  of  these  local  manifestations,  lasting  for  years  in 
many  cases  until  the  unfortunate  sufferer  dies  from  pure  exhaustion. 

Treatment. — There  is  no  treatment  for  leprosy,  though  injections 
of  Calmette's  antivenene  have  been  reported  as  actually  curing  the 
disease.  I  have  seen,  however,  great  improvement  in  a  few  cases  in 
Syria,,  following  the  free  doses  of  cod-liver  oil. 


1 86  CLINICAL  MEDICINE 

RHEUMATIC  FEVER 

That  rheumatic  fever  is  the  result  of  its  own  special  infecting  agent 
is  now  scarcely  denied  by  anyone.  It  is  equally  plain  that  this  agent 
has  but  little  resemblance  in  its  properties  to  that  of  any  other  infec- 
tion. Thus  it  does  not  resemble  any  of  the  pyogenic  organisms,  whether 
streptococci  or  staphylococci,  because  the  inflammation  which  it  occa- 
sions, whether  in  the  joints  or  in  the  tissues,  is  remarkably  free  from 
pus.  This  is  not  because  the  articular  inflammations  are  not  severe, 
for  if  we  should  see  the  same  amount  of  heat,  redness,  and  swelHng 
occurring  in  a  joint  without  any  rheumatism,  we  would  expect  serious 
structural  changes  to  be  going  on  in  the  tissues  of  the  joint.  But  a 
rheumatic  joint  inflammation,  however  severe,  produces  no  serious 
organic  changes,  and  this  is  further  illustrated  by  the  evanescent  char- 
acter of  the  inflammation  itself,  which  may  seem  to  be  very  great  one 
day,  while  the  next  day  the  whole  process  almost  subsides  and  is 
shifted  to  another  joint,  to  go  through  the  same  stages  there.  In 
fact,  apart  from  the  heart  and  its  appendages,  permanent  sequelae 
of  rheumatic  inflammations  are  uncommon. 

This  statement  also  includes  fettering  of  the  joints,  which  is  often 
very  prolonged,  by  rheumatic  inflammatory  exudates  of  the  sheaths  of 
the  tendons.  Though  this  crippling  may  exist  for  years,  yet  if  due 
to  true  rheumatism,  the  prognosis  is  always  good  for  ultimate  restora- 
tion of  the  normal  movements  by  the  persevering  use  of  hot  water 
douches,  several  times  a  day.  On  the  other  hand,  a  gouty  arthritis, 
however  mild  its  first  onset,  leaves  a  permanent  deposit  in  the  affected 
joint,  besides  characteristic  deposits  in  other  parts  of  the  body,  such  as 
tophi  in  the  external  ear. 

We  might  well  expect,  therefore,  that  the  detection  or  identifica- 
tion of  the  causal  agent  of  this  disease  would  be  difficult,  and  so  it  has 
proved,  leading  the  majority  of  authorities  to  deny  that  it  has  been  dis- 
covered. Numerous  attempts  have  been  made  to  identify  this  organ- 
ism such  as  the  bacillus  of  Achalme,  but  all  in  turn  have  failed  of  general 
acceptance.  This,  therefore,  has  led  to  a  skepticism  which,  in  my 
opinion,  has  gone  too  far.  An  organism  first  described  by  Wassermann 
in  Germany,  and  Triboulet  in  France,  has  been  claimed  by  Poynton 
and  Paine  and  Ainslee  Walker  in  England,  to  be  so  definitely  demon- 
strated as  the  causative  agent  of  this  disease,  that  the  Enghsh  ob- 
servers have  given  it  the  name  of  the  Diplococcus  rheumaticus.  They 
isolated  this  organism  from  the  blood  itself  and  from  the  blood  in  the 
heart  and  from  exudates  in  the  pericardium,  as  well  as  the  effusions  in 
the  joints,  and  finally  from  rheumatic  nodules  in  the  skin,  and  after 


RHEUMATIC   FEVER  1 87 

cultivation,  injected  them  into  rabbits,  with  the  effect  of  producing 
multiple  arthritis  and  both  endocardial  and  pericardial  inflammations, 
similar  to  those  characteristic  only  of  acute  rheumatism,  that  is, 
without  any  pus  formation  or  without  any  permanent  changes  in  the 
tissues.  Their  results,  however,  have  been  denied  by  various  experi- 
menters, on  the  ground  that  this  alleged  Diplococcus  rheumaticus  was 
not  found  by  them  in  the  body  of  those  suffering  from  rheumatic  fever, 
either  during  life  or  after  death,  but  these  negative  statements  are  not 
sufficient  to  disprove  the  positive  result  obtained  by  the  above-men- 
tioned observers.  It  is  quite  conceivable  that  such  evanescent  changes 
which  characterize  rheumatic  inflammations  may  be  caused  by  fluctu- 
ating developments  of  these  specific  micro-organisms. 

Clinically,  the  only  arthritic  inflammation  which  may  be  mistaken 
for  rheumatism  is  that  produced  by  the  gonococcus,  and  occasionally 
that  which  occurs  in  scarlatina,  but  the  gonococcus  not  infrequently 
causes  true  ankylosis  of  the  affected  joints  and  scarlatinal  arthritis  very 
commonly  gives  rise  to  purulent  collections,  neither  of  which  changes 
happen  in  true  rheumatism. 

Unlike  other  inflammatory  infections,  rheumatism  leaves  the  lym- 
phatic tissues  and  glands  intact,  but,  as  we  might  expect,  serous  mem- 
branes are  often  involved,  and  the  synovial  membranes  of  joints.  In 
some  cases  the  lung  also  becomes  involved  by  extension  both  from  the 
pleura  and  the  pericardium,  gi^ang  rise  to  true  but  secondary  pneu- 
monic processes  in  the  affected  lungs. 

A  striking  confirmation  of  the  specific  infection  of  rheumatism  being 
the  organism  named  by  Poynton  and  Paine,  Diplococcus  rheumaticus, 
is  found  in  the  phenomena  accompanying  the  disease  called  chorea. 
Chorea  is  now  generally  admitted  as  resulting  from  the  same  agent 
which  causes  rheumatic  fever.  It  is  also  accompanied  very  com- 
monly with  both  endocarditis  and  pericarditis,  while  Poynton  and 
Paine  have  plainly  demonstrated  the  presence  of  the  Diplococcus 
rheumaticus  in  the  cerebrospinal  fluid  of  patients  aft'ected  with 
chorea. 

Heart  Affections. — Rheumatic  fever  would  not  be  a  grave  disease, 
for  its  mortality  is  quite  low,  were  it  not  for  its  occasioning  serious 
affections  of  the  heart  and  of  its  appendages.  The  commonest  form 
of  these  cardiac  affections  is  endocarditis,  which  in  time  involves 
the  valves  of  the  heart,  particularly  the  mitral  valves  and  less  com- 
monly the  aortic.  The  pulmonary  valves  are  but  rarely  affected. 
Owing  to  the  high  ratio  of  fibrin  in  the  blood,  the  edges  of  the  valves 
begin  to  show  first  roughening  and  then  warty  growths  lining  the 


1 88  CLINICAL  MEDICINE 

edges  of  these  structures,  giving  rise  to  the  sounds  characteristic  of 
these  valvular  changes.  At  first  these  changes  do  not  affect  very 
materially  the  circulatory  apparatus,  but  in  time  they  produce  cica- 
tricial contractions  which  may  seriously  derange  the  normal  action  of 
the  valves  either  by  making  them  incompetent  or,  in  the  case  of  the 
mitral  valves,  stenosed.  Mitral  stenosis  is  always  a  serious  matter,  as 
it  tends  to  be  progressive,  as  will  be  more  fully  described  in  the  sec- 
tion on  Diseases  of  the  Heart.  After  the  affection  of  the  mitral,  the 
aortic  cusps  are  likewise  involved,  though  usually  only  half  as  often 
as  the  mitral.  Not  infrequently  both  the  mitral  and  the  aortic  valves 
are  simultaneously  impHcated.  The  case  of  the  aortic  valvular  incom- 
petence, accompanied  by  regurgitation,  is  far  more  common  than 
aortic  obstruction. 

Along  with  endocarditis,  rheumatism,  from  its  predilection  for 
serous  membranes,  is  prone  to  give  rise  to  pericarditis,  as  will  herein- 
after be  described. 

When  the  endocarditis  and  pericarditis  coexist  we  shall  also 
inevitably  have  myocarditis.  In  this  affection  the  muscular  fibers 
of  the  heart  undergo  considerable  fatty  degeneration,  and  such  gen- 
eral weakening  that  dilatation,  particularly  of  the  left  chambers,  takes 
place.  It  is  uncommon  to  have  any  severe  rheumatic  affection  of 
the  heart  occur  without  dilatation  and  enfeeblement  of  the  heart's 
action,  so  as  to  be  itself  a  not  uncommon  cause  of  death,  especially 
in  children. 

Hyperpyrexia. — A  fatal  complication  of  rheumatic  fever,  but 
obscure  in  its  origin,  is  the  supervention  of  hyperpyrexia,  in  which 
the  temperature  rapidly  rises  to  io8°  or  iio°  F.  It  usually  occurs  in 
the  first  attack,  about  the  middle  of  the  second  week,  but  cases  have 
occurred  in  the  second  and  in  the  third  attack.  The  first  symptoms 
are  a  subsidence  of  the  articular  pains,  accompanied  by  rapid  rising 
of  the  temperature.  The  serious  nature  of  this  compHcation  should 
always  be  borne  in  mind  when  the  thermometer  reads  above  104°  F. 
As  a  rule,  notwithstanding  the  high  degree  of  fever  the  mind  remains 
clear,  but  at  other  times  the  hyperpyrexia  is  accompanied  by  dehrium 
or  even  convulsions.  If  the  proper  treatment  is  not  at  once  adopted, 
the  fever  ends  in  stupor  and  in  terminal  coma.  The  treatment  of  these 
cases  is  the  same  as  in  the  hyperpyrexia  and  coma  of  sunstroke,  namely, 
the  cold  bath. 

Treatment. — The  cold  bath  is  the  only  means  known  for  dealing 
with  this  dangerous  complication  and  should  be  administered  at  once, 
its  temperature  being  about  65°  F.    The  patient  should  be  actively 


RHEUMATIC   FEVER  1 89 

rubbed  while  immersed  as  in  the  cold-bath  treatment  of  typhoid  fever, 
and  the  temperature  carefully  noted  every  few  minutes,  without  the 
patient  being  removed  from  the  bath.  He  should,  however,  be  re- 
moved when  the  temperature  has  fallen  5  degrees,  because  the  ther- 
mometer will  continue  to  fall  to  normal  or  even  below. 

The  presence  of  pneumonia  or  heart  complications  do  not  contra- 
indicate  these  baths,  nor  does  the  occurrence  of  shivering  until  the 
effects  of  a  dram  of  the  compound  spirits  of  sulphuric  ether  given  in 
an  ounce  of  camphor-water  has  first  been  tried.  After  the  patient 
has  recovered  from  the  bath,  his  temperature  must  be  carefully 
watched,  for  in  the  course  of  an  hour  or  so  the  hyperpyrexia  sets  in 
again,  so  that  cases  have  been  reported  in  which  twenty  baths  have 
been  necessary  to  stop  the  recurrence  of  the  hyperp;yTexia  before  it 
finally  gave  in.  In  one  case  of  my  own  the  hyperpyrexia  rapidly 
passed  into  coma,  but  recourse  to  the  cold  bath  was  the  only  thing 
which  would  restore  the  patient  to  his  senses.  After  continuing  these 
relapses  for  twenty-four  hours  he  finally  recovered,  whereupon  the 
joints  began  to  be  affected  in  the  usual  way. 

Symptoms. — A  precursor  of  a  rheumatic  infection  occurs  so  fre- 
quently that  it  may  rightly  be  pronounced  as  the  first  step  in  the 
process,  namely,  tonsillitis,  especially  if  suppurative.  For  a  number 
of  years,  I  questioned  the  patients  in  my  hospital  wards,  if  previous 
to  any  joint  involvement  they  had  suffered  from  sore  throat,  and  on 
careful  inquiry  found  that  this  antecedent  had  occurred  in  fully  80 
per  cent.  The  rule  was  that  the  sore  throat  took  the  form  of  tonsil- 
litis and  would  seem  to  give  an  incubation  period  of  a  full  week  before 
the  joints  began  to  be  involved.  In  fully  50  per  cent,  of  those  cases, 
who  had  a  history  of  more  than  one  attack,  sore  throat  preceded  the 
development  of  rheumatism.  This  is  a  point  of  some  practical  im- 
portance, for  I  have  often  cured  a  chronic  tendency  to  rheumatic 
inflammation  by  repeated  douching  of  the  throat. 

Rheumatic  fever  is  not  ushered  in,  like  other  infections,  by  a 
rigor.  The  general  antecedents  are  slight  chilHness,  anorexia,  and  a 
heavily  coated  tongue  such  as  that  always  present  in  tonsilKtis. 
After  a  short  but  variable  period,  a  joint  begins  to  be  painful.  Here 
it  is  well  to  note  the  contrasts  which  are  present  between  the  first 
attack  of  rheumatic  arthritis  and  gouty  arthritis,  as  these  two  joint 
inflammations  are  frequently  confounded.  In  rheumatic  arthritis,  a 
number  of  joints  in  different  parts  of  the  body  are  involved  with  the 
first  attack,  while  in  gouty  arthritis  the  rule  is  that  only  one  joint  is 
attacked,  and  that  in  the  lower  extremities,  especially  in  the  big  toe. 


IQO 


CLINICAL   MEDICINE 


It  is  not  until  the  joints  of  the  lower  extremities,  such  as  the  toes  and 
ankles,  have  been  repeatedly  attacked,  it  may  be  for  years,  that  the 
knee  follows  suit.  Once  gout  reaches  the  knee  then  it  becomes  poly- 
arthritic,  while  rheumatism  is  polyarthritic  with  the  very  first  attack. 
Years  ago  I  drew  attention  to  the  difference  between  the  most  painful 
points  in  the  affected  joints  of  these  two  diseases,  as  hereinafter  noted 
in  my  section  on  Gout.  In  rheumatism  of  the  knee,  for  example,  the 
pain  is  most  ehcited  on  pressure  in  the  course  of  the  tendons,  such  as 
above  and  below  the  patella,  but  in  gout  they  are  distinctly  most 
pronounced  by  pressure  on  the  condyles.  Likewise  in  gouty  fingers, 
pain  is  at  once  ehcited  by  pressing  the  transverse  diameter  of  the  joint, 
while  in  rheumatism  it  is  limited  to  the  tendons  above  and  below  the 
articulation. 

Other  accompaniments  of  rheumatism,  and  of  considerable  diag- 
nostic importance,  are  the  subcutaneous  nodules  especially  in  children. 
They  may  vary  in  size  from  a  small  shot  to  a  large  pea  and  may  develop 
on  the  finger  and  wrist  or  on  other  parts  of  the  body,  but  notably  on 
the  scapula.  When  found,  either  in  rheumatism  or  in  chorea,  they 
are  a  sure  indication  of  rheumatic  disease  and  are  notably  frequent 
when  the  mitral  valve  is  involved,  though  their  origin  is  not  at  all  due 
to  emboHsm.     As  a  rule,  they  are  not  painful. 

Various  cutaneous  eruptions  are  also  associated  with  rheuma- 
tism, sometimes  taking  the  form  similar  to  scarlatinal  erythema,  at 
other  times  accompanied  by  urticaria,  and  purpuric  infiltrations, 
going  along  with  true  arthritic  affections,  which  go  by  the  name  of 
Schonlein's  peliosis  rheumatica.  As  all  of  these  symptoms  may  de- 
velop in  chorea,  their  relationship  to  rheumatism  is  undoubted. 

Rheumatic  fever  rapidly  raises  the  temperature  to  102°  or  104°  F. 
and  with  but  sUght,  if  any  morning  remissions,  and  this  fever  may  last 
with  some  fluctuation  for  four  to  six  weeks.  The  old  saying  that  an 
attack  of  acute  rheumatism  means  six  weeks  in  bed  is  not  without 
justification. 

One  of  the  accompaniments  of  rheumatic  fever  is  profuse  sweat- 
ing, which  is  very  general  and  accompanied  by  a  sour  smell.  This 
sweating  may  also  show  general  sudamina  or  minute  vesicles  on  the 
skin.  It  is  by  no  means  a  trivial  matter,  because  there  can  be  no  doubt 
that  locahzed  chilHng  of  the  skin  over  the  thoracic  viscera  paves  the 
way  for  internal  inflammation  of  the  pleura,  pericardium,  and  endo- 
cardium, and,  therefore,  calls  for  special  measures  to  be  adopted. 

Treatment  of  acute  rheumatic  fever  will  be  both  local  and  inter- 
nal.    There  is  nothing  so  characteristic  of  rheumatic  inflammations 


RHEUMATIC    FEVER  I91 

as  the  extreme  hyperesthesia  of  the  skin  with  pain  on  either  movement 
or  pressure.  To  reheve  this,  some  authorities  recommend  fixation 
of  the  affected  joints,  by  spHnts  or  even  by  starch  bandages.  These 
measures  are  quite  ineffective,  the  best  local  appHcation  being  to  cover 
the  whole  inflamed  area  with  cotton  batting  so  as  to  exclude  the  air, 
while  the  pressure  is  much  better  prevented  by  the  soft  uniform  pro- 
tections so  afforded.  Anodyne  liniments  are  not  of  much  efficacy, 
with  perhaps  the  exception  of  the  belladonna  hniment.  Cotton  bat- 
ting is  particularly  called  for  to  protect  the  heart  and  this  should  be 
continued  throughout  the  whole  course  of  the  disease.  On  account 
of  the  accompanying  perspiration,  the  patient  should  not  He  between 
sheets,  but  always  between  blankets,  and  Dr.  T.  K.  Chambers  very 
properly  recommends  that  in  auscultation  the  stethoscope  should  be 
cautiously  appHed,  without  in  any  way  exposing  the  surface  of  the  skin. 
Every  chill  of  the  surface  will  be  promptly  followed  by  aggravation  of 
the  inflammatory  process  going  on  underneath  that  area  of  the  skin. 

If  the  pain  of  the  joints  continues  the  patient  should  take  a  draft 
containing  lo  gr.  of  chloral,  ^  gr.  of  morphin,  with  2  drops  of  dilute 
hydrocyanic  acid.  The  medicinal  treatment  of  rheumatic  fever  is  of 
great  importance,  the  danger  of  heart  compKcations  never  being  forgot- 
ten. Since  the  introduction  of  the  saHcylates,  which  have  such  a 
marked  control  over  the  pains,  an  unjustifiable  abandonment  of  the  old 
alkaline  treatment,  first  introduced  by  Fuller,  has  occurred,  with  the 
result,  according  to  my  firm  conviction,  that  cardiac  complications 
are  more  common  now  than  before.  However  striking  may  be  the 
improvement  in  the  pain  and  other  accompaniments  of  rhQumatic 
fever  caused  by  the  saHcylates,  these  drugs  do  not  diminish  in  any 
way  the  tendency  to  cardiac  inflammations,  while  an  adequate  and 
early  recourse  to  the  alkaHne  treatment  undoubtedly  lessens  the 
occurrence  of  both  endocarditis  and  pericarditis.  Instead  of  Fuller's 
treatment,  which  is  somewhat  compHcated,  bicarbonate  of  soda  in 
|-dram  doses  may  be  given  along  with  20  gr.  of  citrate  of  potash 
every  two  or  three  hours,  until  the  urine  becomes  alkaHne,  whereupon 
the  original  doses  may  be  taken  less  frequently.  Should  the  urine, 
however,  become  acid  again,  the  original  frequency  of  the  doses  should 
be  resumed. 

As  in  other  acute  febrile  diseases,  it  is  well  to  begin  the  treatment 
with  a  calomel  purge,  consisting  in  an  adult  of  5  gr.  of  calomel  and  35  gr. 
of  compound  jalap  powder,  to  be  repeated  once  or  twice  a  week  if  the 
tongue  becomes  heavily  coated.  The  treatment  of  acute  rheumatism 
by  the  saHcylates  began  with  Dr.  Maclaga,  who   first  gave  salicin, 


192  CLINICAL  MEDICINE 

with  marked  reduction  of  the  fever  and  pain.  This  was  soon  fol- 
lowed by  the  general  employment  of  the  saHcylates,  particularly  in 
the  form  of  saHcylate  of  soda.  It  is  now  common  to  prescribe  for 
an  adult  15  gr.  of  sodium  saHcylate  every  two  or  three  hours,  according 
to  the  severity  of  the  symptoms.  This  often  produces  very  annoy- 
ing tinnitus  and  occasionally  delirium.  In  some  cases  marked  by 
enfeeblement  of  the  heart,  heavy  doses  of  the  sodium  salt  should  be 
avoided,  and  should  be  accompanied  by  from  i  to  2  gr.  of  caff  ein  citrate, 
and,  still  better,  by  the  hypodermic  injection  of  7  gr.  of  camphor  dis- 
solved in  20  min.  of  sterihzed  olive  or  almond  oil,  as  this  is  the  most 
certain  of  all  our  cardiac  stimulants. 

Of  all  acute  fevers,  rheumatism  causes  the  most  rapid  and  pro- 
nounced anemia.  This  should  never  be  treated  with  any  prepara- 
tion of  iron,  but  toward  the  decline  of  the  attack  cod-Hver  oil  should 
be  perseveringly  administered.  As  intimated  above,  prophylaxis  of 
recurrent  attacks  should  always  be  attempted,  and  this  can  only  be 
done  by  douching  the  throat  with  from  i  to  2  gallons  of  hot  normal 
saline,  to  which  a  dram  of  chlorate  of  potash  and  5  drops  of  the  oil 
of  peppermint  or  wintergreen  has  been  added  to  each  gallon.  This 
douche  should  be  administered  night  and  morning  by  means  of  a 
fountain  bag  suspended  5  feet  above  the  patient's  head.  He  should 
lean  over  a  basin,  keeping  his  mouth  wide  open,  during  the  douche. 
The  flow  will  then  be  directed  from  the  nozzel  over  the  base  of  the 
tongue  until  it  impinges  on  the  posterior  wall  of  the  pharynx,  and  then 
returns  to  the  mouth  by  way  of  the  tonsil,  thus  thoroughly  cleansing 
this  chief  portal  of  the  infection. 

In  chronic  cases  the  skin  should  always  be  carefully  protected,  and 
undoubted  efficacy  against  further  chill  is  caused  by  the  ancient  prac- 
tice of  anointing  the  body,  preferably  with  cocoanut  oil  to  which  oil 
of  wintergreen  (|  dram  to  the  pint)  has  been  added. 

CHOREA 

Clinical  Course. — In  the  majority  of  cases  chorea  is  a  disease  of 
childhood  due  to  a  leptomeningitis  caused  by  the  Diplococcus  rheu- 
maticus.  Such  a  meningitis,  being  rheumatic,  will  not  be  exudative 
or  purulent,  but,  owing  to  its  seat,  will  be  accompanied  by  special 
motor  and  cerebral  symptoms.  The  cerebral  symptoms  show  them- 
selves in  a  state  of  mental  irritability,  with  loss  of  control  and  inability 
to  fix  the  attention,  so  that  the  child  should  be  at  once  removed  from 
school,  for  if  he  remains  there  the  speech  may  become  affected  and 
the  articulation  mumbled  and  indistinct.     In  severe  cases  the  acts 


CHOREA  193 

of  swallowing  may  become  choreic,  and  then  so  impossible  that  the 
nutrition  is  gravely  impaired.  Ordinarily,  however,  the  earliest 
symptoms  are  disorders  of  the  seats  of  the  highest  cerebral  activities, 
viz.,  awkwardness  in  the  use  of  the  fingers  in  the  habitual  acts.  The 
lower  extremities  may  also  partake  in  the  motor  disturbance,  and  the 
gait  becomes  irregular  or  ataxic. 

As  might  be  expected  in  a  cerebral  trouble,  it  is  often  limited  for  a 
time  to  one  side.  But,  Kke  all  affections  caused  by  the  Diplococcus 
rheumaticus,  chorea  should  be  anxiously  watched  for  its  tendency  to 
produce  endocarditis.  As  we  have  seen,  rheumatic  arthritis  may  be 
trivial  in  children,  though  the  heart  be.  gravely  involved.  And  this 
is  particularly  true  in  chorea,  for  endocarditis  occurs  oftener  in  children 
with  chorea  than  it  does  when  a  frank  rheumatic  arthritis  is  present. 
Many  a  case  of  serious  and  lifelong  heart  disease  may  be  traced  to  an 
attack  of  chorea  in  childhood  which  had  been  overlooked  because  it 
was  then  so  insidious. 

The  characteristic  muscular  movements  which  have  given  the 
name  of  St.  Vitus'  dance  to  the  disease  are  just  what  we  might  ex- 
pect from  a  diffuse  irritation  of  the  motor  area  in  the  brain  cortex. 
Instead  of  localized  twitching,  still  less  of  fibrillar  movements,  the  whole 
muscle  jerks  from  end  to  end. 

These  movements  are  not  co-ordinated,  nor  can  they  be  made  so  by 
the  will.  But  the  choreic  movements  by  no  means  involve  all  muscu- 
lar structures,  those  of  the  face  and  extremities  being  much  more 
affected  than  those  of  the  trunk.  This  is  as  might  be  expected,  for  the 
muscles  of  the  face  and  of  the  hands,  for  example,  are  activated  by  the 
highest  cortical  centers,  while  those  of  the  neck  and  tnmk  are  more  un- 
der the  sway  of  the  spinal  centers.  The  child  begins  with  queer  grim- 
aces or,  as  commonly  expressed,  "makes  faces,"  opening  and  shutting 
its  eyes  or  Hps  or  contracting  its  cheeks,  with  a  special  tendency  to 
turn  the  face  toward  its  shrugging  shoulders,  and  the  movements  grow 
more  pronounced  as  we  go  down,  the  elbows  jerking  more  than  the 
shoulders,  while  the  hands  and  fingers  are  the  worst  of  all.  Corre- 
sponding to  the  irregular  movements  of  the  upper,  are  those  of  the 
lower,  extremities.  The  thighs  are  not  often  affected,  but  below  the 
knees  choreic  movements  are  so  constant  as  to  make  the  patients 
often  stagger  because  the  ankles  and  toes  do  not  act  together. 

Like  all  true  rheumatic  affections,  relapses  are  frequent,  especially 
at  the  same  time  of  year  with  the  first  attack,  which  commonly  occurs 
in  the  early  spring,  rheumatic  arthritis  sometimes  coinciding  with 
chorea  or  following  it.     One  effect,  however,  should  be  noted,  and  that 

13 


194  CLINICAL  MEDICINE 

is  the  tendency  of  rheumatism  to  produce  anemia.  This  is  a  constant 
accompaniment  of  rheumatic  fever  in  adults,  but  is  no  less  marked  in 
choreic  children,  so  that  some  writers  ascribe  chorea  to  anemia,  where- 
as it  is  the  rheumatic  poison  which  causes  both  the  anemia  and  the 
chorea. 

Rheumatic  attacks  are  prone  to  vary  in  severity  from  time  to 
time,  and  hence  chorea  does  the  same,  particularly  when  its  exciting 
causes  coincide  with  the  onset,  such  as  fright. 

We  have  dwelt  on  the  rheumatic  origin  of  chorea  in  children  because 
of  its  important  relations  to  treatment,  as  we  shall  see.  But  there 
are  examples  of  choreic  disorders  which  have  nothing  to  do  with 
rheumatism.  One  of  the  worst  cases  that  I  have  ever  seen  was  in  a 
young  soldier  in  our  Civil  War,  which  was  caused  by  pure  fright  when 
he  went  into  his  first  battle.  He  had  to  he  constantly  on  a  mattress 
surrounded  by  other  mattresses  to  prevent  bodily  injury  from  the 
incessant  violent  movements  of  his  arms  and  legs. 

Chorea  in  adults  may  be  a  very  grave  disease.  It  may  occur  in 
pregnancy  in  the  third  or  fourth  month  or  not  until  shortly  after  de- 
livery. Its  seriousness  is  then  due  to  acute  melanchoHa  supervening, 
with  signs  of  great  prostration,  from  which  the  patient  may  die.  The 
significance  of  the  changes  found  postmortem  in  the  brain  is  very 
uncertain. 

Treatment. — The  list  of  remedies  recommended  for  chorea  is  both 
long  and  varied,  a  fact  which  shows  either  that  the  disease  often  gets 
well  spontaneously,  or  that  it  is  difficult  to  cure.  The  first  of  these 
propositions  is  of  common  application  in  chorea,  for  the  great  majority 
of  the  patients  recover,  however  they  be  treated.  But  there  are  cases 
which  go  on  for  months  without  appreciable  change,  though  every 
reputed  remedy  has  been  given  to  them. 

It  is  better,  therefore,  to  aim  at  treating  the  disease  from  the  first 
according  to  the  chief  indications  rather  than  empirically.  In  chil- 
dren we  ought  to  think  of  rheumatism  first  and  of  the  danger  of  endo- 
carditis. The  heart  should  be  examined  at  every  visit.  A  systolic 
murmur  at  the  base  or  at  the  apex  will  often  be  heard,  and  the  char- 
acter of  the  souQd  may  vary  from  day  to  day. 

So  long,  however,  as  the  action  of  the  heart  is  not  appreciably 
quickened  nor  its  rhythm  disturbed,  it  may  be  hoped  that  no  perma- 
nent cardiac  mischief  is  impending. 

But  meanwhile  what  should  be  done?  Prophylaxis  is  here  of  the 
first  importance.  Considering  that  the  portal  of  infection  of  the  rheu- 
matic agent  is  the  tonsils,  the  mouth  should  be  thoroughly  douched 


CEREBROSPINAL   MENINGITIS  1 95 

twice  a  day,  as  recommended  for  diphtheria  and  scarlet  fever.  This 
measure,  of  Itself,  will  often  suffice  to  forestall  endocarditis.  Meantime 
every  precaution  should  be  taken  to  prevent  the  child  with  choreic 
jerkings  from  catching  cold  by  putting  it  in  a  canton  flannel  bag  tied 
securely  about  the  neck,  as  before  recommended,  for  nothing  so  dis- 
poses to  internal  inflammations  as  chill  of  the  surface  when  wet  with 
perspiration. 

Some  authors  highly  recommend  Fowler's  solution  of  arsenic  in 
doses  of  3  or  4  drops  three  times  a  day,  but  in  my  opinion  with  no 
better  results  than  by  the  use  of  such  restoratives  as  iron  and  cod- 
liver  oil. 

CEREBROSPINAL  MENINGITIS 

This  terrible  disease  occurs  both  in  a  sporadic  and  in  an  epidemic 
form.  It  has  not  long  been  mentioned  in  history,  and  was  first  de- 
scribed by  Vieussens,  in  Geneva,  1805,  also  independently  by  Daniel- 
son  and  Mann,  in  Medford,  Mass.,  during  the  same  year.  It  is  caused 
by  the  Diplococcus  intracellularis,  first  described  by  Weichselbaum  in 
1887.  This  organism  settles  in  the  upper  nasal  passages,  where  it 
may  be  found  in  perfectly  healthy  persons,  but  it  then  can  penetrate 
through  the  passages  of  the  ethmoid  bone  and  invade  the  meninges 
at  the  base  of  the  brain,  extending  then  upward  to  the  cortex,  and 
downward  to  the  spinal  cord,  causing  fibrinosis  and  purulent  conditions 
as  it  travels. 

It  is  due  to  its  extensive  exudates  that  it  produces  such  serious 
results.  Plastering,  as  it  were,  the  structures  at  the  base  of  the  brain, 
it  may  involve  one  after  the  other  of  the  cranial  nerves,  particularly 
the  second,  fifth,  seventh,  and  eighth,  causing  optic  atrophy,  per- 
manent deafness,  paralysis  of  one  or  more  of  the  eye  muscles,  and  in 
many  cases  death,  As  it  proceeds  down  it  may  cause  acute  suffer- 
ing from  implicating  the  muscles  of  the  neck,  and  then  of  the  whole 
spinal  system,  causing  muscular  rigidity  and  affecting  both  the  sen- 
sory and  motor  nerves  where  they  emerge  from  the  canal. 

The  clinical  symptoms,  therefore,  are  very  varied.  In  the  majority 
of  the  acutely  fatal  cases  death  occurs  in  the  first  week,  and  in  some 
epidemics  within  twenty-four  hours.  As  a  rule,  the  attack  sets  in 
suddenly,  with  violent  chills,  vomiting,  headache,  and  grave  consti- 
tutional depression.  In  many,  painful  contractions  of  the  muscles 
of  the  neck,  drawing  the  head  backward,  set  in  early,  and  may  then 
proceed  to  make  the  whole  spine  rigid  and  arched  either  backward 
or  to  one  side.  Photophobia  and  sensitiveness  to  sounds  may  then 
develop.     The  pulse  in  children  is  rapid  and  small,  but  in  adults  is 


196  CLINICAL   MEDICINE 

not  uncommonly  slow.  The  pains  in  the  muscles  become  very  severe 
and  are  often  accompanied  by  tremors.  Paralyses  are  not  so  common, 
except  of  the  eye  muscles,  when  strabismus  is  an  important  diagnostic 
symptom. 

Delirium  often  sets  in  early  and,  subsequently,  coma.  This  coma 
may  be  quite  prolonged,  and  is  then  not  necessarily  an  unfavorable 
symptom,  for  the  patient  may  lie  unconscious  from  a  serous  effusion 
in  the  ventricles  of  the  brain,  which  by  its  pressure  may  prevent  the 
purulent  exudations  from  occurring.  I  have  more  than  once  roused 
patients  who  were  thus  comatose  for  days  by  the  apphcation  of  a  large 
blister  to  the  neck. 

In  some  severe  cases  the  mind  is  never  affected.  One  boy  aged 
four  years  who  developed  many  symptoms,  including  total  deafness, 
the  characteristic  rash,  and  spinal  rigidity,  through  seven  weeks  of 
agony  preserved  his  mental  faculties  to  the  very  end.  In  the  acute 
stage  there  is  frequently  universal  hyperesthesia,  but  more  commonly 
it  is  limited  to  the  spinous  processes.  The  temperature  is  irregular  and 
variable,  though  frequently  not  rising  above  102°  F.,  but  there  may  be 
exceptions.  The  cutaneous  symptoms  of  the  disease  are  quite  diag- 
nostic, the  particular  rash,  which  has  given  the  name  "spotted  fever" 
to  the  disease,  is  always  likewise  variable,  not  occurring  at  all  in  some 
patients,  and  sometimes  disappearing  during  a  remission,  to  appear 
again  during  an  exacerbation.  The  color  of  the  eruption  also  varies, 
sometimes  amounting  to  petechias  and  purple  spots  covering  the  whole 
skin.  Leukocytosis  is  an  early  and  constant  feature,  ranging  from 
25,000  to  40,000  per  c.mm.,  its  variations  having  no  bearing  upon 
the  severity  of  the  case,  and  persisting  even  in  most  protracted  cases. 
The  course  of  the  disease  cannot  be  predicted,  because  it  is  so  variable; 
as  Hirsch  states,  "it  may  range  between  a  few  hours  and  several 
months."  Convalescence  is  extremely  tedious,  and  may  be  inter- 
rupted by  all  sorts  of  compHcations  and  sequelae. 

Remissions  in  the  fever  are  very  irregular.  When  the  disease  be- 
comes chronic,  as  it  sometimes  does,  lasting  for  two  months  or  more, 
most  serious  marasmus,  characterized  by  a  compHcated  series  of  symp- 
toms, may  occur.  Pneumonia  frequently  arises,  which  may  or  may  not 
closely  resemble  ordinary  croupous  pneumonia.  We  have  already 
alluded  to  the  actions  of  the  optic  nerve  and  of  the  still  more  common 
affections  of  the  auditory  nerve.  These  may  cause  both  permanent 
blindness  and  permanent  deafness,  as  in  the  case  of  the  celebrated 
Helen  Keller;  but  affections  of  the  ear  are  more  common  than  of  the 
eye,  and  Von  Ziemssen  states  that  in  the  deaf  and  dumb  institutions 


ERYSIPELAS  I97 

of  Bamberg  and  Nuremberg  the  majority  of  the  pupils  have  become 
deaf  from  epidemic  cerebrospinal  meningitis.  Kernig's  sign  is  one  of 
special  diagnostic  value — when  the  thigh  is  flexed  at  right  angles  to  the 
abdomen,  the  leg  can  be  extended  upon  the  thigh  nearly  in  a  straight 
line,  but  if  meningitis  be  present,  strong  contractions  of  the  flexors 
prevent  the  full  extension  of  the  leg  on  the  thigh.  Another  important 
diagnostic  sjonptom  occurs  from  making  a  lumbar  puncture  and  wdth- 
drawing  the  fluid  from  within  the  canal.  If  meningitis  be  present, 
this  fluid  enters  the  hypodermic  syringe  under  markedly  increased 
pressure,  and  when  examined  under  the  microscope  shows  abundant 
intracellular  organisms  or  diplococci  which  can  be  readily  distinguished 
from  other  organisms,  such  as  the  pneumococcus. 

As  before  stated,  this  disease  prevails  as  an  epidemic  in  many  re- 
gions both  in  Europe  and  in  America.  As  a  rule,  country  districts 
have  been  more  affected  than  cities,  but  in  New  York  in  1904  and  1905 
there  were  6755  cases  and  3455  deaths.  The  epidemic  outbreaks 
have  occurred  most  frequently  in  the  winter  and  spring.  On  the 
other  hand,  it  has  been  very  prevalent  in  large  barracks,  particularly 
among  young  recruits.  Everywhere,  however,  children  are  much  more 
liable  to  the  disease  than  adults,  the  disease  appearing  not  at  all  di- 
rectly contagious,  and  it  is  rare  to  have  more  than  i  or  2  cases  in  a 
house.  On  the  other  hand,  meningitis  carriers  are  persons  who  have 
the  germ  in  their  throats  or  noses,  but  who  are  themselves  unaffected, 
which  fact  undoubtedly  plays  an  important  role  in  transmitting  the 
disease. 

Sporadic  meningitis  is  found  Kngering  in  all  the  large  cities  of  this 
country,  and  that  it  is  the  same  as  the  epidemic  form  is  proved  by 
the  demonstration  of  its  specific — Diplococcus  intracellularis. 

Treatment. — Up  to  within  a  very  recent  period  the  treatment  of 
this  formidable  disease  was  well-nigh  hopeless.  Symptomatically 
the  severity  of  the  symptoms  might  be  allayed  by  the  application  of 
ice-bags  to  the  head  and  to  the  spine,  and  in  some  cases  I  have  found 
partial  reHef  by  the  administration  of  dram  doses  of  the  fluidextract 
of  ergot  in  adults,  but  the  only  measure  which  has  proved  of  real 
service  is  the  administration  of  the  serum  prepared  by  Dr.  Simon 
Flexner,  the  use  of  which  has  been  favorably  reported  in  widely  dis- 
tributed epidemics  both  in  America  and  in  Europe. 

ERYSIPELAS 

Erysipelas  occurs  under  three  forms — medical,  surgical,  and  puer- 
peral.    This  affection  is  probably  not  contagious,  as  is  maintained  by 


198  CLINICAL  MEDICINE 

some,  because  the  streptococcus  to  which  it  is  due  requires  a  lesion  to 
have  taken  place  in  the  parts  which  it  invades;  hence  it  is  like  other 
streptococci  usually  found  upon  the  skin  or  mucous  membranes. 
Surgeons  who  most  commonly  observe  this  affection  are  prone  to  ig- 
nore the  medical  kind,  but,  chnically,  there  can  be  no  doubt  that  this 
latter  form  may  develop  first  in  the  system,  then  afterward  appear 
upon  the  skin. 

As  to  the  medical  form,  the  mode  of  its  infection  is  obscure,  but 
nevertheless  undoubted.  Thus  I  have  predicted  that  a  given  case 
would  within  twenty-four  hours  show  that  it  was  erysipelas,  while 
not  a  sign  of  the  inflammation  was  yet  discoverable  anywhere  on  the 
surface.  This  prediction  was  based  upon  these  clinical  facts:  first,  the 
sudden  occurrence  of  a  violent  chill,  accompanied  with  the  signs  of 
an  acute  febrile  infection.  During  this  chill  the  patient's  temperature 
rises  very  rapidly,  sometimes  reaching  107°  F.,  the  skin  becomes  burn- 
ing hot,  as  it  does  in  pneumonia,  without,  however,  the  least  sign  of  the 
lungs  being  involved.  After  some  twenty-four  hours  of  these  symp- 
toms, a  red  spot  develops  upon  the  face,  which  soon  afterward  shows  all 
the  characteristics  of  spreading  erysipelas.  The  fever  and  constitu- 
tional symptoms,  however,  distinctly  precede  any  cutaneous  manifes- 
tation, and,  therefore,  cannot  be  due  to  any  skin  derangement.  It  is 
probable  that  all  three  forms  are  caused  by  the  same  organism  which 
was  first  definitely  identified  by  Fehleisen,  who  cultivated  it  outside 
the  body  on  various  media,  and  then  produced  its  characteristic  lesions 
by  inoculation.  Fehleisen 's  identification,  however,  has  been  called 
in  question  by  other  observers,  who  claim  that  it  is  no  different  from  a 
Streptococcus  pyogenes,  but  Fehleisen's  coccus  specifically  differs 
from  the  Streptococcus  pyogenes,  in  that  when  it  is  inoculated  in 
healthy  persons  it  causes  no  formation  of  pus.  Moreover,  the  cHnical 
course  of  this  inflammation  is  quite  different  from  any  of  the  numerous 
pus-generating  varieties  of  the  streptococci. 

The  medical  variety  also  dift'ers  from  the  surgical  in  running  a 
shorter  course,  which  ends  by  crisis,  the  temperature  usually  dropping 
to  nearly  normal  on  the  fifth  day.  This  affection  was  considered 
contagious  first  in  England  about  1850,  and  then  in  France,  by  Trous- 
seau and  Velpeau,  and  lastly  in  Germany,  by  Wernher  in  1862  and 
Volkmann  in  1869.  But  the  disease  cannot  properly  be  called  con- 
tagious when  it  does  not  spread  from  person  to  person  by  mere 
proximity,  but  rather  by  the  infection  of  a  wound  or  abrasion  pre- 
viously present.  Streptococci  that  cause  abscesses  do  not  cause  ery- 
sipelas even  when  their  contents  flow  out  through  the  cutaneous  in- 


ERYSIPELAS  1 99 

cision,  whose  edges  they  therefore  necessarily  bathe.  The  most  fre- 
quent method  of  conveying  the  contagion  is  by  the  hands  of  nurses  or 
of  operators.  This  disease  may  begin  first  on  the  mucous  membrane 
and  then  spread  to  the  skin,  or,  vice  versa,  may  begin  in  the  skin 
and  spread  to  the  mucous  membrane,  its  commonest  seat  being  on 
the  face  or  in  the  mouth.  The  virus  chngs  closely  to  furniture,  bed- 
ding, clothing,  and  the  like.  Som.e  persons  show  a  marked  disposition 
to  the  disease,  suffering  from  many  attacks  of  it  throughout  their 
lives.     Sometimes  the  same  spot  is  attacked  time  after  time. 

Surgical  erysipelas  usually  begins  from  some  abrasion  or  wound 
upon  the  surface,  and  from  thence  spreads  not  by  the  blood-vessels, 
but  in  the  lymphatic  vessels  of  the  corium.  The  specific  nature  of 
the  erysipelatous  streptococcus  has  been  conclusively  demonstrated 
by  its  artificial  inoculation  for  the  purpose  of  arresting  the  growth  of 
lupus  or  even  of  some  malignant  diseases.  In  such  cases  the  induced 
erysipelas  may  arrest  for  the  time  the  growth  of  malignant  tumors. 
While  erysipelas  itself  does  not  usually  cause  suppuration,  on  the 
other  hand,  inoculation  from  suppurating  wounds  does  not  cause  Feh- 
leisen's  erysipelas.  After  an  erysipelatous  inflammation  the  skin 
desquamates,  and  this  infection  is  produced  oftener  by  the  scales  from 
desquamation  than  by  any  other  method  of  propagation. 

The  incubation  period  of  erysipelas  has  been  estimated  at  from  three 
to  seven  days,  but  when  introduced  by  inoculation  it  may  appear  in 
fifteen  hours.  It  is  best  shown  when  it  attacks  the  face  and  head, 
beginning  as  a  sharply  defined  patch  of  redness,  either  on  the  cheeks  or 
more  commonly  at  the  junction  of  the  mucous  membranes  of  the  nose 
and  skin.  It  may  begin,  however,  near  the  margin  of  the  hairy  scalp. 
The  affected  skin  becomes  red,  hot,  swollen  and  shiny,  with  a  feeling 
of  burning  pain.  The  patch  then  spreads  by  direct  continuity  to  sur- 
rounding parts,  always  showing  a  sharply  defined,  raised  red  line. 
Where  the  disease  spreads  over  loose  tissues  much  serous  effusion 
occurs  into  them,  hence  the  eyehds  become  enormously  swollen  and 
the  eyes  closed.  The  ears  are  thickened  and  the  features  become  quite 
unrecognizable.  Blebs,  more  or  less  large,  may  also  appear  on  the 
skin,  which,  when  they  burst,  dry  up,  leaving  adherent  crusts.  When 
the  disease  spreads  to  the  scalp  there  is  much  headache,  accompanied 
by  local  tenderness  and  swelling,  but  without  marked  redness.  It  is 
under  the  scalp  that  abscesses  may  form,  not  directly  due  to  erysipelas, 
but  to  a  mixed  infection  from  the  scalp,  which  may  pass  down  the  neck 
and  then  to  the  body  in  general.  When  it  spreads  over  a  joint,  effusion 
takes  place  into  its  cavity,  but  in  simple  erysipelas  it  is  never  purulent. 


200  CLINICAL  MEDICINE 

The  most  dangerous  condition  in  erysipelas  occurs  when  it  attacks  the 
mucous  membrane  of  the  throat.  The  throat  is  extremely  painful, 
preventing  deglutition,  and  causing  much  pain  and  difficulty  in  swal- 
lowing. Great  edematous  swelUng  also  occurs,  especially  affecting 
the  uvula,  but  the  most  perilous  event  is  when  erysipelas  invades  the 
larynx,  as  it  causes  there  great  edema  of  the  epiglottis  and  ar)denoid 
folds.  This  edema  comes  on  very  suddenly,  and  may  terminate 
hfe  unless  the  parts  are  quickly  scarified,  so  as  to  reduce  this  danger- 
ous swelling,  but,  notwithstanding  this,  it  often  necessitates  recourse 
to  tracheotomy  to  save  life. 

Following  erysipelas  the  most  important  compHcation  is  diffuse 
cellulitis.  This  may  lead  to  general  pyemia,  producing  pleurisy, 
pericarditis,  meningitis,  or, the  disease  may  spread  along  the  ear  or 
Eustachian  tube,  leading  to  abscess  of  the  middle  ear  with  all  its 
complications.  Repeated  attacks  of  erysipelas  occurring  season  after 
season  lead  to  much  thickening  of  the  skin  and  deformity. 

Treatment.^Being  under  certain  conditions  contagious,  no  case 
of  erysipelas  should  be  admitted  into  a  surgical  ward,  and  it  is  equally 
imperative  that  such  a  case  should  never  be  allowed  with  puerperal 
patients.  If,  however,  the  nurses  and  attendants  are  very  careful  to 
disinfect  their  hands,  these  dangers  are  much  lessened.  To  the  tense, 
inflamed  skin  vaseHn  should  be  freely  appHed,  or  else  the  Hme-water 
Hniment,  with  a  dram  of  oil  of  cinnamon  to  the  pint. 

In  mild  cases  little  need  be  done  except  to  keep  the  bowels  free. 
The  face  should  be  covered  with  a  lint  mask,  with  apertures  for  the 
mouth,  nose,  and  eyes,  kept  moist  by  a  lotion  of  lead  and  opium,  with 
I  dram  of  oil  of  cinnamon  to  the  pint.  When  the  erysipelas  extends 
to  the  scalp,  nothing  is  so  efficacious  as  an  ice-bag.  If  the  erysipelas 
begins  in  an  extremity,  and  travels  upward,  a  band  of  tincture  of 
iodin  should  be  made  about  the  Hmb  3  inches  above  the  advancing 
erysipelas.  In  the  severer  forms  of  this  disease  occurring  in  drunkards 
or  debilitated  subjects,  the  case  should  be  treated  on  the  stimulant 
plan,  when  alcohol  may  be  freely  used,  while  the  patient's  strength 
is  sustained  by  copious  drinks  of  milk  and  lime-water.  The  best 
stimulant  for  these  conditions  should  be  camphor,  dissolved  in  steril- 
ized olive  or  almond  oil,  and  administered  subcutaneously  in  doses 
of  I  gram  (7I  gr.)  to  20  min.  of  the  oil.  Formerly  the  tincture  of 
perchlorid  of  iron,  in  dram  doses,  was  lauded  as  a"  specific  in  erysipelas, 
given  every  two  or  three  hours,  but  it  is  a  question  if  it  is  better  than 
other  methods  of  treatment. 

Puerperal  Form. — Fortunately,  this  form  at  present  is  well-nigh 


ERYSIPELAS  20I 

extinct  in  every  civilized  country,  but  when  I  first  came  to  New  York 
in  the  year  1862  it  was  justly  considered  one  of  the  most  dreaded 
scourges  either  of  Europe  or  of  America.  In  illustration  I  may  say  that 
while  I  was  a  student  of  medicine  in  the  year  1858  I  copied  in  my 
note-book  an  item  from  a  medical  journal  that,  in  the  maternity  hos- 
pital in  Vienna,  Dr.  Semmelweis  had  introduced  the  practice  of  all  the 
attendants  upon  the  hospital  inmates  of  washing  their  hands  in  chlorin 
water,  and  then  carefully  cleansing  their  fingers  with  brushes,  with  the 
result  that  the  mortality  from  puerperal  fever  in  that  institution  had 
fallen  from  57  to  12  per  cent.  No  one  then  knew  why  this  happened. 
Semmelweis  himself  did  not  live  to  reap  his  just  reward,  but  died  a 
persecuted  and  much  maligned  man.  In  that  same  maternity  hospi- 
tal in  Vienna,  though  it  has  been  much  enlarged  since  Semmelweis' 
day,  the  mortahty  from  puerperal  fever,  which  was  28  per  cent,  of 
deaths  from  all  cases  in  that  institution  in  his  time,  has  fallen  off  in 

*the  past  year  to  i  of  i  per  cent. 

During  the  first  year  of  my  residence  in  New  York  I  attended  a 
discussion  which  occupied  several  consecutive  sittings  of  the  New  York 
Academy  of  Medicine,  on  the  "Nature  and  Treatment  of  Puerperal  or 
Childbed  Fever."  That  discussion  was  participated  in  by  the  most 
distinguished  physicians  of  this  city,  as  well  as  by  some  eminent  men 
from  other  places.  Though  the  gentlemen  who  took  part  in  it  were 
both  gifted  and  conscientious  men,  their  remarks  are  melancholy 
enough  reading  to  us,  their  successors,  now,  for  not  one  of  them  had 
the  faintest  conception  of  the  nature  of  the  terrible  malady  they  were 
talking  about.  One  speaker's  remarks,  however,  I  particularly  re- 
call. His  private  practice  took  him  to  the  homes  of  the  rich  oftener 
perhaps  than  did  that  of  any  other  colleague.     He  particularly  com- 

.  plained  of  the  fearful  epidemic  of  puerperal  fever  that  winter,  not  only 
in  his  Bellevue  Hospital  wards,  but  also  in  the  private  families  which 
he  attended.  If  he  now  Hved  he  probably  would  not  have  one  case 
of  puerperal  fever  in  his  family  practice  in  many  years,  but  what  he 
did  then  was  to  go  first  to  his  dreadfully  infected  hospital  wards,  and 
then  step  into  his  carriage  and  drive  as  a  real,  though  totally  uncon- 
scious, messenger  of  death  to  a  young  mother  lying  in  her  richly  fur- 
nished home. 

This  is  only  one  illustration  of  the  priceless  gifts  of  modern  medi- 
cine to  the  world.  Since  then  science  has  discovered  the  relationship 
of  micro-organisms  to  disease  and  death,  which  were  formerly  totally 
unknown. 


202  CLINICAL   MEDICINE 

PYEMIA 

It  may  be  well  to  refer  here  to  infections  of  the  blood  itself  with 
pyogenic  organisms,  leading  to  the  condition  termed  "pyemia."  The 
origins  of  this  blood  infection  are  very  numerous,  one  illustration  of 
which  is  from  an  extension  of  a  suppurative  process  in  the  middle  ear, 
through  a  small  but  very  thin  bony  septum,  which  will  infect  a  venous 
sinus  lying  over  the  partition.  Pus  organisms  thus  entering  the  sinus, 
pass  down  the  jugular  vein  and  then  to  the  right  side  of  the  heart,  often 
producing  abscesses  in  the  lungs,  but  also  return  to  the  left  side  of  the 
heart  and  then  are  distributed  to  the  liver  and  other  viscera  generally. 
Another  condition  is  in  cases  of  ulcerative  endocarditis,  giving  rise  to 
what  may  be  called  a  general  spray  of  minute  emboli,  lodging  every- 
where, and  causing  hemorrhages  in  the  skin  and  extremities,  and  mul- 
tiple abscesses  in  every  part  of  the  body.  Chronic  infections  of  septic 
endocarditis  are  often  characterized  by  daily  chills,  followed  by  fever, 
which  may  be  so  periodic  as  closely  to  resemble  malaria.  The  differ-' 
ential  diagnosis  from  malaria  in  severe  cases  is  easily  made  from  the 
countenance  of  the  patient,  indicating  a  grave  condition  quite  different 
from  an  attack  of  ague.  On  the  other  hand,  the  infecting  organism 
may  be  the  pneumococcus,  which  is  specially  prone  to  attack  the  joints. 
One  of  the  most  severe  cases  of  suppuration  in  joints  that  I  have  met 
was  due  to  the  Staphylococcus  pyogenes  aureus.  On  the  other  hand, 
some  cases  may  be  due  to  the  Bacillus  coH.  The  only  help  for  these 
general  blood  infections  we  owe  to  the  very  recent  advances  in  vaccine 

therapy. 

DENGUE 

Dengue  usually  occurs  in  a  pandemic  form,  and  is  not  exceeded, 
even  by  influenza,  in  its  local  prevalence.  It  is  a  disease  almost  ex- 
clusively confined  to  tropical  or  subtropical  countries.  In  one  Mediter- 
ranean city  of  about  100,000  inhabitants  it  suddenly  developed,  until 
it  was  maintained  that  no  person  escaped.  It  is,  however,  in  no  sense 
a  fatal  complaint,  which  is  noteworthy,  considering  the  severity  of  its 
chnical  symptoms.  It  usually  sets  in  without  any  premonitory  symp- 
toms, beginning  with  severe  pains,  in  many  cases,  in  every  part  of  the 
body,  but  especially  in  the  joints  and  muscles,  the  whole  body  becom- 
ing sore,  and  violent  headaches  both  in  the  front  and  back.  In  some 
cases  the  pains  are  localized  in  the  eyeballs.  The  fever  is  usually  quite 
pronounced,  and  may  reach  106°  or  107°  F.,  but  out  of  proportion  to  the 
severity  of  these  symptoms  the  patients  are  not  much  prostrated,  being 
rather  fettered  in  their  movements  of  muscles  and  joints.  The  attack 
usually  lasts  a  full  week  and  is  followed,  on  its  subsidence,  by  symptoms 


BERIBERI  203 

of  general  debility.     The  pulse,  even  at  the  height  of  the  disease,  does 

not  present  any  pecuUarities  other  than  those  of  frequency.     Unlike 

other  severe  febrile  affections,  it  has  almost  no  compHcations.     Its 

etiology  as  regards  its  causative  agent  is  unknown.      By  some  it  has 

been  ascribed  to  the  bite  of  a  mosquito,  which  is  improbable,  because 

mosquitoes  are  no  more  frequent  either  before  or  during  the  epidemic. 

Its  treatment  is  purely  symptomatic,  as  in  other  cases  of  temporary 

fever. 

BERIBERI 

This  curious  disease,  which  is  both  endemic  and  epidemic  on  the 
eastern  coasts  of  the  Asiatic  continent,  comes  to  our  notice  by  cases 
occurring  in  our  seaports.  But  it  prevails  among  the  Chinese  in  CaH- 
fornia.  Personally,  I  have  seen  only  2  cases.  The  first,  a  girl  of 
American  parentage,  who  in  early  childhood  contracted  it  while 
residing  in  Japan,  with  the  result  of  arrest  of  her  mental  development 
for  Hfe.  The  second  was  a  sailor  who  contracted  it  in  Brazil.  Be- 
sides paralysis  of  his  limbs,  he  was  the  only  case  I  have  ever  seen  of 
complete  paralysis  of  the  diaphragm,  so  that  the  abdominal  muscles 
largely  protruded  every  time  he  took  an  inspiration. 

The  disease  is  essentially  one  of  peripheral  neuritis,  caused  by  an 
unidentified  toxin,  and  occurs  in  three  principal  clinical  forms. 

Clinical  Course. — The  first  is  characterized  by  wandering  and  ill- 
defined  s3anptoms,  the  patient  at  the  beginning  appearing  simply 
to  have  caught  cold,  accompanied  by  wandering  pains  in  different 
parts  of  the  body  and  by  various  paresthesias,  such  as  numbness  and 
tingling.  These  may  be  limited  to  the  lower  limbs,  but  ere  long  signs 
of  muscular  weakness  come  on,  accompanied  by  tenderness  to  pressure 
of  the  muscles.  These  symptoms  may  temporarily  disappear,  to  re- 
cur, however,  especially  in  the  advent  of  warm  weather,  and  such 
signs  may  come  and  go  for  many  years. 

In  the  second  form,  weakness  and  paralysis  of  the  muscular  system 
is  the  most  pronounced.  This  muscular  paralysis  shows  the  same 
character  of  tenderness  to  pressure  of  the  impHcated  muscles,  but, 
besides  this,  signs  of  muscular  atrophy  appear  in  different  parts  of  the 
body,  occasionally  even  in  the  muscles  of  the  face.  Ere  long  the 
patient  may  be  unable  to  walk  or  to  raise  the  arms. 

The  third  form  is  the  dropsical,  characterized  by  anasarca  or  sub- 
cutaneous or  even  subserous  effusions,  the  water  accumulating  in 
both  pleurae. 

Meantime,  in  each  of  these  forms,  but  particularly  in  the  dropsical 
variety,  signs  of  heart  weakness  develop,  due  to  the  invasion  of  the 


204  CLINICAL   MEDICINE 

myocardium  and  accompanied  by  palpitation  and  dyspnea.  In  one 
of  these  attacks  the  patient  may  suddenly  die.  Occasionally  the 
symptoms  of  heart  failure  are  so  pronounced  from  the  beginning  that 
some  writers  speak  of  a  fourth  or  pernicious  form,  so  characterized  by 
signs  of  heart  failure  that  the  patients  die  within  twenty-four  hours, 
but  most  of  these  cases  survive  for  several  days. 

As  to  the  etiology,  there  is  wide  diversity  of  opinion  even  among 
those  who  have  had  the  most  experience  in  its  study. 

Treatment. — The  most  striking  facts  about  the  prevention  and 
treatment  of  this  disease,  are  found  in  the  effect  of  changes  in  diet. 
Thus,  Takagi,  the  surgeon-general  of  the  Japanese  Navy,  completely 
banished  this  disease  from  his  ships,  in  which  it  had  been  ruinously 
prevalent,  by  ordering  the  diet  to  be  composed  of  much  more  nitroge- 
nous food  than  that  to  which  the  sailors  had  been  previously  accus- 
tomed. On  the  other  hand,  Java  physicians  have  had  similar  success 
in  prescribing  that  the  coolies,  among  whom  beriberi  was  very  prev- 
alent, should  take  only  rice  which  had  not  been  shelled  of  its  pericarp. 
It  would  seem,  therefore,  from  these  facts  that  a  suitable  dietary  is 
more  important  than  anything  else,  both  for  preventing  and  for  curing 
this  curious  complaint. 

This,  however,  leaves  unexplained  the  outbreak  of  this  disease  in 
certain  isolated  and  widely  separated  locaHties,  such  as  the  Richmond 
Asylum,  in  DubUn,  Ireland,  and  the  State  Insane  Asylum,  at  Tusca- 
loosa, Alabama,  in  both  of  which  cases  it  is  stated  there  was  much 
overcrowding  in  the  building.  These  isolated  outbreaks  of  this  disease 
have,  therefore,  afforded  some  support  to  those  authorities  who  claim 
that  beriberi  is  a  truly  infectious  disease;  but  what  the  infecting  agent 
is  has  never  been  demonstrated. 

Besides  the  adoption  of  changes  of  diet,  local  measures  for  the 
effects  of  the  disease,  such  as  muscular  atrophy,  may  be  adopted,  on 
the  same  line  as  in  other  similar  cases,  such  as  massage  of  the  wasted 
muscles  and  applications  of  electricity.  Baelz  recommends,  in  early 
cases,  a  free,  use  of  the  saHcylates  (15  or  20  gr.)  four  or  five  times  a  day. 

PELLAGRA 

This  severe  and  curious  disease  was  first  named  pellagra  (smarting 
skin)  by  FrapolH,  in  the  beginning  of  the  eighteenth  century. 

It  has  prevailed  so  extensively  where  maize  is  an  article  of  diet 
that  it>  has  been  ascribed  to  fungus  growth  upon  moldy  maize.  But 
the  area  of  maize  consumption  is  now  known  to  be  wider  than  that  of 
pellagra,  and  pellagra  is  found  where  maize  is  at  least  not  an  ordinary 


PELLAGRA  205 

diet.  Recent  researches,  while  they  have  added  many  facts  to  our 
previous  knowledge  of  the  disease,  have  left  its  specific  origin  and 
nature  still  obscure.  An  illustration  of  this  statement  is  that  Dr.  L.  W. 
Sambon,  at  a  meeting  of  the  British  Medical  Association  in  1905,  sug- 
gested that  pellagra  was  probably  protozoal  in  origin,  and  that  the 
protozoan  was  communicated  by  sand  flies,  just  as  sleeping  sickness  is 
by  the  African  tsetse.  This  view  was  also  endorsed  by  Sir  Patrick 
Manson. 

Pellagra  prevails  especially  in  Italy,  in  the  South  of  France,  in 
Spain,  Roumania  and  Corfu,  also  in  Egypt  and  India.  Of  late  years 
it  has  appeared  in  the  United  States,  particularly  in  North  Carolina, 
South  CaroKna,  Maryland,  Georgia,  Alabama,  and  Texas. 

Symptoms. — As  a  rule,  it  is  a  chronic  disease,  beginning  in  the 
spring  and  subsiding  in  the  summer,  but  returning  with  greater  sever- 
ity the  following  spring,  and  so  on  for  subsequent  years,  until  the 
patient  succumbs.  An  acute  form,  however,  has  been  reported  as 
occurring  epidemically  in  the  Mt.  Vernon  hospital  for  colored  insane, 
in  Alabama,  with  the  high  mortahty  of  64  per  cent.  Pellagra  be- 
gins, in  adults,  with  headache,  dizziness,  ringing  in  the  ears,  a  burn- 
ing sensation  of  the  skin,  especially  in  the  hands  and  feet,  and  diarrhea; 
at  the  same  time  a  red  rash  appears  on  the  skin,  resembling  erysipelas, 
the  red  spots  being  tense  and  painful,  especially  when  exposed  to  the 
sun.  When  these  spots  disappear  toward  the  close  of  the  summer,  the 
skin  remains  rough  and  dry.  With  each  successive  year  the  results  of 
the  attacks  become  more  pronounced,  by  extensive  changes  of  the  skin, 
until  it  resembles  that  of  a  mummy.  Meanwhile,  other  symptoms 
develop,  such  as  red  and  dry  tongue,  a  burning  feehng  in  the  mouth, 
pain  on  swallowing,  and  diarrhea.  Ere  long  serious  S3Tnptoms  fol- 
low, due  to  implication  of  the  nervous  system,  shown  first  by  ptosis 
of  the  eyelids,  dilatation  of  the  pupil,  and  other  signs  which  are  explained 
by  changes  revealed  at  postmortem  examination,  consisting  of  degen- 
eration in  the  spinal  cord  of  the  posterior  columns  of  Goll  and  of 
Burdach,  similar  to  those  found  in  tabes.  Meanwhile,  pigmentary 
changes  proceed  in  the  skin  which  resemble  those  of  Addison's  disease. 
Atrophy  of  the  muscles  follow,  and  finally  death  from  exhaustion. 

The  only  treatment  which  has  been  at  all  successful  has  been  that 
reported  by  Babes,  following  his  administration  of  atoxyl,  which  shows 
that  this  disease  is  of  protozoal  origin,  similar  to  the  sleeping  sickness 
of  Africa. 

It  is  probable  that  urotropin  would  be  of  service,  10  gr.  four  times 
a  day,  with  a  similar  dose  of  benzoate  of  soda. 


2o6  CLINICAL   MEDICINE 

ACTINOMYCOSIS 

This  is  a  rare  disease,  and  is  due  to  an  infection,  not  by  bacterium, 
but  by  a  fungus  called  Strep tothrix  actinomyces.  I  have  had  i  case 
in  my  practice,  that  of  a  farmer,  who  came  for  a  serious  bronchitis 
involving  his  right  lung.  The  expectoration  was  profuse  and  some- 
what fetid.  The  patient  maintained  that  he  was  sure  it  was  caused 
from  inhalation  of  musty  dust  while  he  was  winnowing  oats  in  his 
barn.  The  diagnosis  of  this  complaint  can  only  be  made  by  the  dis- 
covery of  the  fungus  itself.  Many  of  the  cases  begin  in  the  lungs,  and 
form  abscesses  which  may  infect  the  whole  system,  including,  accord- 
ing to  some  reports,  even  the  brain.  Some  of  these  abscesses  may  oc- 
cur in  bone,  while  others  may  invade  such  organs  as  the  liver  and  spleen, 
when,  as  is  often  the  case,  the  mycehum  first  develops  in  the  mouth,  and 
it  may  attack  the  jaw,  forming  a  tumor  closely  resembhng  a  sarcoma. 
The  patients,  when  the  affection  becomes  at  all  generalized,  die  with 
the  symptoms  of  chronic  pyemia. 

Treatment. — The  only  remedy  which  is  reported  to  have  been  of 
any  service  is  potassium  iodid  in  doses  of  from  40  to  60  gr.  a  day. 

RELAPSING  FEVER 

This  is  a  specific  infectious  disease  whose  agent  was  first  identified 
by  Obermeier  in  1873  as  due  to  a  spirochete.  It  is,  however,  an  an- 
cient disease,  as  it  is  very  probably  described  by  Hippocrates,  and  then 
and  now  so  common  among  badly  fed  people  that  it  long  ago  received 
the  name  of  "famine  fever,"  prevailing  especially  during  war  in  be- 
sieged cities. 

In  1869  it  prevailed  as  an  epidemic  in  New  York  and  Philadelphia, 
but  has  died  out  completely  since,  as  it  has  in  Europe  also,  owing  doubt- 
less to  improvement  in  the  food  supply.  We  may  note  here  that  fam- 
ines were  of  frequent  occurrence  in  every  country  of  Europe  during 
the  Middle  Ages,  and  were  doubtless  due  to  the  great  difficulties  of 
transportation  of  food-stuffs  from  place  to  place.  Nowadays  no 
such  deficiency  can  be  threatened  anywhere  without  the  telegraph 
quickly  announcing  it  and  the  railroad  as  promptly  reheving  it.  This 
formerly  relapsing  fever  is  now  well-nigh  extinct. 

Relapsing  fever  is  not  a  fatal  disease.  Murchison  quoted  the  deaths 
as  only  4  per  cent.,  and  generally  only  from  intercurrent  complications. 

Symptoms. — The  incubation  may  be  very  short,  or  from  five  to 
seven  days  after  exposure.  The  invasion  is  sudden,  with  chills,  fever, 
and  great  pain  in  the  back  and  in  the  limbs.  The  temperature  rises 
rapidly  and  may  reach  104°  F.  on  the  first  day.    The  pulse  is  frequent, 


MALTA    OR    MEDITERRANEAN    FEVER  207 

ranging  from  no  to  130.  Swelling  of  the  spleen  appears  early  and 
jaundice  is  not  infrequent.  The  blood  becomes  charged  with  the 
spirochete,  along  with  some  leukocytosis.  After  lasting  for  five  or  six 
days  the  fever  is  said  to  end  in  a  crisis,  the  temperature  falling  to  nor- 
mal or  even  below  it;  the  convalescence  seems  rapid,  so  that  the  patient 
may  be  up  and  about  in  a  few  days,  but  the  relapse  will  occur  usually 
by  the  fourteenth  day,  sometimes  with  rigors  and  with  all  the  former 
symptoms  again.  A  second  crisis  occurs  from  the  twentieth  to  the 
twenty-third  day,  and  again  the  patient  recovers  rapidly.  As  a 
rule,  the  relapse  is  shorter  than  the  original  attack.  A  second  and  a 
third  may  occur,  and  there  are  instances  on  record  of  even  a  fourth. 
In  some  epidemics  there  are  no  relapses  after  the  first  attack,  or  there 
may  be  two  or  more  relapses,  which  leave  the  patient  much  exhausted. 
In  some  epidemics  a  troublesome  ophthalmia  occurs,  and  intercurrent 
complications,  such  as  hematuria  or  pneumonia. 

Treatment  is  symptomatic,  because  we  have  no  special  remedy  for 
the  complaint. 

MALTA  OR  MEDITERRANEAN  FEVER 

This  peculiar  endemic  fever  was  proved  by  Bruce,  in  1886,  to  be  due 
to  a  specific  micro-organism  present  in  the  blood,  which  he  named 
''Micrococcus  melitensis,"  which  caused  great  trouble  to  the  British 
Government  for  many  years,  from  the  number  of  soldiers  and  sailors 
who  yearly  had  to  be  invalided  home  from  the  garrisons  of  Malta 
and  Gibraltar,  affecting  not  only  the  soldiers,  but  the  sailors  of  the 
British  fleet.  But  though  Bruce  identified  the  micro-organism,  its 
origin  remained  for  eighteen  years  unknown,  until  the  British  Govern- 
ment requested  a  commission,  appointed  by  the  Royal  Society,  to 
investigate  it.  This  commission  established  the  fact,  in  1904-05, 
that  this  organism  first  infects  goats  and  then  passes  into  their  milk. 
As  goats'  milk  was  the  only  milk  which  the  soldiers  or  sailors  con- 
sumed, the  government  substituted  for  it  condensed  milk  brought  from 
England,  with  the  result  that  whereas  in  1905  there  were  750  cases, 
in  1907  there  were  only  7  cases  among  soldiers,  but  none  in  the  fleet. 

There  could  scarcely  be  a  better  illustration  than  this  of  the  value 
of  bacteriologic  examination  in  dealing  with  an  epidemic;  a  fact  also 
illustrated  in  the  stamping  out  of  such  awful  destroyers  of  the  human 
race  as  the  bubonic  plague  and  Asiatic  cholera.  Besides  Malta  and 
Gibraltar,  the  cities  along  the  Mediterranean  shore,  especially  Naples, 
also  reported  the  existence  of  this  disease,  which  extended  to  India  and 
China. 


2o8  CLINICAL  MEDICINE 

The  mortality  in  this  infection  is  not  high,  usually  less  than  7  per 
cent.,  but  its  course  is  very  characteristic.  The  period  of  incubation 
is  from  six  to  ten  days;  the  fever  is  very  irregularly  remittent,  so  that 
it  has  often  been  mistaken  for  malarial  infection.  The  fever  may  last 
for  from  two  to  three  weeks,  followed  by  complete  remission  for  two 
days,  after  which  it  sets  in  as  bad  as  ever,  and  may  continue  for  six 
months,  leaving  the  patient  anemic  and  exhausted.  During  its  course 
rheumatoid  pains  may  occur  and  the  joints  become  inflamed  and  swol- 
len; as  the  remissions  occur,  profuse  sweats  are  common. 

Treatment. — Quinin  has  been  used  in  large  doses  for  this  infection, 
but  without  any  avail.  The  disease  has  to  run  its  course,  so  that  it  is 
possible  that  phenacetin  given  in  15-gr.  doses  four  times  a  day  may 
mitigate  the  symptoms.  Prophylaxis  is,  after  all,  the  chief  indication, 
for  the  infection  can  be  wholly  prevented  by  abandoning  the  use  of 
infected  milk. 


CHAPTER    IV 
INFECTIONS  COMMUNICABLE  BY   INOCULATION 

MALARIA 

In  no  class  of  infections  has  the  progress  of  medical  science  been 
so  signal  as  in  the  discovery  of  the  mode  of  entrance  of  infections  by 
inoculation.  A  good  illustration  of  this  is  shown  in  the  first  infection 
which  we  shall  treat,  under  that  erroneous  term  "malaria."  From  the 
earhest  times  this  cause  of  disease  and  death  in  the  human  race  was 
supposed  to  be  due  to  simple  inhalation  of  poisoned  air,  hence  its 
name,  mal-aria.  Another  common  term,  equally  mistaken,  was  that 
of  miasmatic  disease,  the  conception  being  that  it  was  caused  by  an 
emanation  from  the  soil,  especially  of  marshy  and  low  locahties,  of  a 
disease-producing  vapor  or  gas.  This  was  a  natural  inference  from  the 
prevalence  of  malarial  infections  in  marshy  locahties  everywhere  except 
in  the  Arctic  regions.  The  good  effects  of  drainage  of  wet  soils 
seemed  thus  to  be  easily  explained.  This  mistake  led  to  further  er- 
roneous suppositions  that  the  water  from  soggy  locahties  was,  when 
swallowed,  often  the  cause  of  severe  fever.  This,  however,  did  not 
explain  the  marked  periodicity  of  the  attacks  of  ague.  Nevertheless, 
the  other  apparent  accompaniments  of  malarial  affections  seemed  too 
plain  to  dispossess  the  minds  of  both  the  profession  and  of  the  laity  of 
the  wide  prevalence  of  malaria  in  all  its  forms.  It  was  not  until  our 
own  day  that  this  venerable  error  was  dissipated.  The  first  step  was 
taken  in  1880  by  Laveran,  a  French  army  surgeon  in  Algiers,  who  dis- 
covered that  the  blood  of  malarial  patients  was  full  of  an  organism 
which  attacked  the  red  blood-corpuscles.  This  discovery  remained 
for  years  unexplained  as  to  the  mode  of  entrance  of  the  parasite  into 
the  blood  and  body,  and  it  was  not  explained  until  the  remarkable 
researches  of  two  American  army  surgeons,  Drs.  Kilbourne  and 
Theobald  Smith,  who  were  deputed  by  the  United  States  Government 
to  investigate  the  cause  of  the  Texas  cattle  fever.  This  fever  affected 
cattle  coming  from  Texas,  but  only  when  they  passed  through  a  certain 
district  in  the  state  of  Kansas.  Drs.  Kilbourne  and  Smith  investi- 
gated the  soil,  water,  and  air  of  the  Kansas  district  without  discover- 
ing any  explanation  of  the  infection,  but  they  finally  found  that  there 

14  209 


2IO  CLINICAL  MEDICINE 

was  a  tick  living  in  the  grass  of  the  infected  region  which  crept  up  the 
hoofs  of  the  cattle  and  bit  them  just  above  the  fetlock.  Examining 
these  ticks,  they  found  about  their  mouths  swarms  of  protozoa  which 
were  exactly  similar  to  the  protozoa  which  multiply  so  amazingly  in 
the  blood  of  the  cattle.  They  then  took  specimens  of  these  ticks  and 
carried  them  to  Texas,  and  had  them  bite  cattle  there,  with  the  im- 
mediate result  of  infecting  them  just  the  same  as  they  were  in  Kansas. 
The  same  kind  of  ticks  transported  to  IlHnois  and  Ohio,  where  this 
fever  was  wholly  unknown,  produced  the  identical  disease  there,  of  a 
protozoan  called  Piroplasma  bigeminum.  This  discovery  gave  the 
hint  of  parasites  invading  the  blood-corpuscles  by  the  bites  of  insects. 
Profiting  by  the  hint  suggested  by  the  Texas  cattle  fever,  a  number  of 
ItaHan  observers  demonstrated  that  a  particular  variety  of  mosquito, 
called  the  anopheles,  abounding  in  the  Pontine  marshes  of  Italy,  could 
infect  persons  with  malarial  fever,  though  the  insects  themselves  were 
transported  to  localities  where  malaria  was  unknown,  including  Lon- 
don itself.  This  led  to  very  extensive  researches  by  Marchifava,  Celli, 
Councilman,  and  others,  who  confirmed  and  further  extended  our 
knowledge  of  the  different  varieties  of  mosquitoes.  The  general 
result  was  that  this  infection  is  due  to  the  presence  in  the  blood  of 
an  animal  parasite,  which  enters  and  grows  in  the  red  corpuscle,  and 
whose  different  species  produce  the  varying  cHnical  forms  of  the  mala- 
rial fevers.  Thus  the  tertian  ague  is  caused  by  a  different  parasite 
from  the  quartan,  and  both  of  these  are  different  from  the  estivo-au- 
tumnal  parasite,  which  latter  is  much  the  most  difficult  form  to  treat. 
The  particular  forms  of  these  parasites  can  be  readily  distinguished 
from  one  another  under  the  microscope,  and,  in  fact,  at  present  the 
diagnosis  of  malaria  is  not  estabhshed  until  repeated  examinations  of 
the  blood  show  their  presence  in  the  red  corpuscles. 

We  may  say  here  that  the  mosquito  was  supposed  to  be  the  cause 
of  malaria  fully  2000  years  ago  by  Varro  and  Columella,  but  this  hy- 
pothesis, though  maintained  by  numerous  subsequent  writers,  remained 
unverified  until  Bignami,  the  Italian,  in  1896  demonstrated  that  the 
infection  of  malaria  is  caused  by  one  only  out  of  125  species  of  mos- 
quito, the  Anopheles  claviger.  This  was  further  confirmed  by  Ross  in 
1897,  who  demonstrated  that  the  hematozoa  of  birds  were  transported 
by  a  certain  species  of  mosquito.  The  genus  anopheles  contains  50 
species,  all  of  which  can  transmit  the  disease.  Specimens  of  this 
mosquito  were  taken  to  a  convent  on  the  Apennines,  now  turned  into 
a  prison,  and  allowed  to  bite  the  prisoners  there,  with  the  result  that 
they  immediately  contracted  malaria.     Some  of  the  same  mosquitoes 


MALARIA  211 

were  sent  to  London,  where  two  young  medical  men  allowed  their  hands 
to  be  bitten  by  them,  with  the  result  that  they  forthwith  contracted 
the  disease  in  London,  where  it  was  wholly  unknown,  and  it  is  now  gen- 
erally admitted  that  it  is  only  this  genus  of  mosquito  which  spreads 
malarial  infection.  Of  course,  such  a  specific  animal  parasite  can 
neither  be  a  gas,  a  bad  air,  nor  a  miasm.  The  fact,  however,  re- 
mains that  this  mosquito  can  give  malaria  only  by  sucking  the  blood 
of  a  person  infected  by  these  organisms;  but  which  came  first,  the 
mosquito  or  the  infected  human  being,  is  like  determining  the  old  ques- 
tion, whether  the  egg  came  first  or  the  hen  which  laid  it.  The  prac- 
tical deduction,  however,  is  that  to  rid  a  district  of  malaria  we  must 
first  either  exterminate  the  insects  which  are  its  carriers,  or  quarantine 
the  patient  whose  blood  abounds  with  this  protozoan. 

Biologically,  it  is  incorrect  to  call  the  parasite  of  malaria  a  Plas- 
modium, since  its  true  position  is  among  the  sporozoa.  These,  when 
sucked  by  the  mosquito  from  the  infected  patient,  undergo  specific 
changes  in  the  intestine  of  the  mosquito,  and  then,  at  certain  stages, 
they  leave  the  intestine  and  collect  about  the  insect's  proboscis,  so  as 
to  be  ready  thereby  to  infect  the  blood  in  the  way  that  the  Texas 
ticks  infected  the  blood  of  the  cattle.  The  life  cycle  of  these  parasites 
in  the  blood  is  now  very  well  determined,  so  that  we  can  say  that  the 
paroxysms  of  the  chill  and  the  onset  of  the  fever  correspond  in  time 
with  the  formation  and  maturation  of  the  parasitic  spores ;  this  process 
taking  in  one  species  thirty-six  hours,  and  in  another  seventy- two  hours, 
while  in  the  estivo-autumnal  varieties  it  may  be  quotidian,  tertian, 
quartan,  or  hebdominal  in  its  intervals.  The  infection  of  the  blood  by 
these  parasites  is  always  a  serious  matter.  Since  the  introduction  of 
quinin,  when  given  early,  especially  at  the  beginning,  it  was  errone- 
ously supposed  that  ague  might  be  cured  by  this  drug  in  less  than  a 
week,  but  it  may  be  safely  said  that  no  case  of  ague  can  be  cured  by 
drugs  in  less  than  six  weeks,  while  in  other  forms,  especially  the  esti- 
vo-autumnal, the  blood  may  never  be  freed  from  them  for  many  years, 
if  at  all.  I  have  a  patient  now  who  has  been  under  my  treatment  for 
twelve  years,  and,  in  spite  of  a  great  variety  of  remedies  employed,  is 
liable  to  relapses  with  appearances  of  the  parasites  every  few  weeks. 

Symptoms. — Malarial  disease  being  due  to  an  invasion  of  the  blood 
by  an  animal  parasite,  presents  a  great  many  contrasts  with  true  bac- 
terial infections.  The  first  thing  to  note  is  that  these  animal  parasites 
are  of  three  distinct  species,  which  can  be  readily  distinguished  from 
one  another  by  their  appearance  under  the  microscope.  The  first 
is  that  of  the  tertian  parasite,  and  the  second  is  that  of  the  quartan,  but 


212  CLINICAL  MEDICINE 

the  most  dangerous  is  the  so-called  estivo-autumnal  form,  which 
derives  its  name  from  its  prevalence  in  temperate  cHmates  during  the 
summer  and  autumn  months,  but  in  the  tropics  it  prevails  the  year 
round.  Its  presence  can  be  easily  recognized  by  its  crescentic  form, 
and,  as  such,  should  be  carefully  studied  by  the  student.  While  the 
various  serious  developments  which  occur  in  malarial  disease  may  be 
caused  by  any  one  of  its  specific  forms,  yet  much  the  commonest 
and  most  intractable  species  is  the  estivo-autumnal,  which  shows  a 
great  variety  in  its  clinical  symptoms,  an  example  of  which  occurred 
to  me  at  the  beginning  of  my  medical  experience  in  the  cases  of  three 
young  Englishmen  who  were  prostrated  by  an  attack  of  fever  while 
visiting  the  shores  of  the  Dead  Sea  in  Palestine.  The  extraordinary 
experience  with  this  fever  there,  was  that  no  patient  survived  the 
third  attack,  while  the  majority  succumbed  from  the  second  attack. 
The  symptoms  were  those  of  heart  failure  with  great  dyspnea  or  con- 
gestion of  the  lungs,  while  the  whole  body  was  bedewed  with  a  cold 
perspiration.  The  attacks  were  definitely  tertian.  I  saw  them  after 
they  had  passed  through  the  first  attack,  when  my  medical  instructor 
prevented  a  return  on  the  second  day,  during  the  remission,  by  admin- 
istering 30  gr.  of  quinin  at  two-hour  intervals  until  they  had  taken 
90  gr.  It  was  not  until  90  gr.  had  been  swallowed  that  the  first 
signs  of  ringing  in  the  ears  appeared,  but  they  were  then  safe,  though 
they  had  to  continue  large  doses  of  quinin  for  several  weeks.  In 
other  places  the  brunt  of  the  pernicious  attack  is  spent  upon  the 
abdominal  organs,  characterized  by  excruciating  pains  at  the  epigas- 
trium, with  vomiting  and  diarrhea,  so  much  so  that  they  have  often 
been  treated  for  Asiatic  cholera.  In  every  instance,  however,  the 
correct  diagnosis  can  be  made  only  by  microscopic  examination  of  the 
blood.  Not  uncommonly,  symptoms  of  dysentery  of  a  severe  variety 
set  in,  which  will  be  wholly  unamenable  to  treatment  until  the  connec- 
tion with  malaria  is  discovered.  As  a  rule,  the  temperature  is  high, 
from  103°  F.  upward,  but  in  these  attacks  the  temperature  is  a  very 
uncertain  guide,  some  of  the  worst  forms  presenting  a  low  tempera- 
ture. One  of  the  worst  forms  is  when  the  brain  is  involved,  causing 
rapid  development  of  coma;  the  capillaries  of  the  brain  itself  as  well 
as  those  of  the  meninges  being  crowded  with  parasites.  I  have  known, 
however,  of  an  attack  of  coma  being  suddenly  caused  in  a  day  laborer 
while  digging  a  ditch,  who  was  brought  to  the  hospital  not  only  com- 
atose, but  with  highly  albuminous  urine  filled  with  casts.  The  char- 
acter of  his  pulse,  however,  satisfied  me  that  he  had  no  chronic  kidney 
complaint,  and,  therefore,  that  his  coma  could  not  be  uremic.     An 


MALARIA  213 

examination  of  his  blood  showed  it  charged  with  the  ordinary  tertian 
parasites,  and  quinin  soon  restored  him  from  his  coma  and  relieved 
his  kidneys  as  well. 

In  the  tropics,  however,  with  cases  of  the  estivo-autumnal  type, 
comatose  symptoms  are  of  very  serious  import,  the  onset  in  some  cases 
being  gradual,  while  in  others  profound  stupor  develops  very  rapidly, 
death  occurring  between  the  third  and  sixth  day.  A  common  form  is 
that  of  a  more  or  less  chronic  mixed  infection  with  the  different  spe- 
cies of  the  malarial  parasite,  leading  to  a  long-continued  fever  which  is 
marked  by  irregular  remissions.  In  this  form  the  Hver  suffers  espe- 
cially, becoming  enlarged  and  tender,  the  stomach  becomes  ver>'  irri- 
table, with  copious  vomiting  of  bile-stained  fluids.  This  is  ordinarily 
known  as  the  bilious  remittent  fever,  and  is  easily  confounded  with 
tjrphoid  fever.  The  study  of  the  temperature  curve  will  show  that  it 
does  not  correspond  to  that  of  true  typhoid,  and  here  again  the  dis- 
covery of  the  malarial  organism  in  the  blood  settles  the  diagnosis.  On 
one  occasion  at  the  Roosevelt  Hospital  I  had  3  cases  of  malarial  fever, 
and  typhoid  fever  occurring  simultaneously.  In  2  of  these  the  malarial 
organisms  disappeared  altogether  until  the  typhoid  fever  had  run  its 
course,  when  they  reappeared  during  the  convalescence. 

As  we  have  remarked  before,  the  infection  with  the  malarial  para- 
site is  always  a  serious  matter,  however  easily  it  may  seem  at  first  to 
be  controlled  by  quinin.  Though  the  patient  may  continue  to  feel 
well,  he  is  not  so,  because  when  some  physical  or  mental  strain  occurs 
three  or  six  months  afterward  the  old  malarial  parox^'sm  devel- 
ops as  severe  as  ever.  This  shows  that  the  ordinary  defensive  powers 
of  the  system  are  able  to  hold  the  infection  in  check,  but  no  more,  for 
let  any  extra  call  be  made  upon  the  vital  powers  and  the  whole  disease 
reappears.  An  explanation  of  this  is  furnished  by  a  study  of  the  urine, 
which  for  months  after  an  infection  shows  that  at  a  certain  hour  the 
excretion  of  urea  is  doubled  or  even  trebled.  This  increase,  corre- 
sponding to  what  would  have  been  a  febrile  malarial  paroxysm,  proves 
that  the  treatment  of  malaria  is  virtually  that  of  a  very  chronic  dis- 
ease, subject  to  periodic  exacerbations  which  are  curiously  hebdomi- 
nal  or  weekly  in  their  occurrence,  relapses  commonly  happening  on  the 
seventh,  fourteenth,  twenty-first,  or  twenty-eighth  days.  Other  cases, 
again,  have  a  seasonal  character,  coming  at  intervals  of  six  months  or 
a  year  after  the  original  attack. 

Treatment. — The  treatment  of  malaria  calls  naturally  for  vary- 
ing measures.  Thus  it  [will  differ  according  to  locality.  In  the 
same  places  where  malaria  is  not  particularly  rife,  the  treatment 


214  CLINICAL   MEDICINE 

which  will  suffice  to  control  the  development  of  the  disease  will  call 
for  smaller  doses  than  in  localities  which  are  strongly  infected.  Thus, 
in  malarious  districts  found  along  the  banks  of  the  Thames  in  England 
a  dose  of  12  gr.-  of  quinin  in  the  course  of  twenty-four  hours  will  be 
sufficient,  while  in  most  places  in  the  United  States  the  dose  has  to 
vary  from.  18  to  30  gr.  a  day.  My  own  practice  has  been  to  commence 
the  treatment  with  a  calomel  purge,  and  then  not  to  administer  the 
quinin  alone,  but  always  in  combination  with  an  equal  amount  of 
powdered  ginger.  It  is  a  significant  fact  that  spices  are  throughout  the 
vegetable  kingdom  formed  to  protect  the  inner  bark,  but  especially 
the  seeds  of  the  plant,  for  the  purpose  of  preventing  the  seeds  from  the 
attacks  of  vegetable  fungi  or  of  insects,  and  all  spices  are  virtually 
varieties  of  carbolic  acid,  and  hence  can  be  made  to  promote  the  action 
of  quinin.  It  is  on  this  account  that  that  extraordinary  farrago  called 
Warburg's  tincture,  which  in  its  original  formula  contains  76  ingre- 
dients, including  powdered  snake-skins,  constitutes  such  an  efficient 
substitute  for  quinin  itself.  My  usual  practice  is  to  put  up  equal 
parts  of  powdered  ginger  and  quinin  in  6-gr.  capsules,  and  then  to  ad- 
minister two  of  these  capsules  twice,  three  times,  or  four  times  a  day;  in 
other  words,  giving  12,  18,  or  24  gr.  of  quinin  in  the  first  twenty-four 
hours.  In  some  cases  I  have  added  powdered  capsicum  in  the  pro- 
portion of  I  gr.  to  4  gr.  of  quinin.  Where  this  prescription  is  given  for 
the  first  time  it  may  act  upon  the  bowels,  but  usually  not  after  the 
first  day.  If  the  malarial  attack  be  an  ordinary  tertian,  the  adminis- 
tration of  the  capsules  should  be  begun  on  the  day  of  the  remission: 
two  in  the  forenoon,  two  in  the  afternoon,  and  two  in  the  evening,  with 
a  fourth  dose  on  the  morning  of  the  attack,  given  two  hours  before  its 
expected  onset.  If  this  medication  suffices  to  prevent  the  occurrence 
of  the  paroxysm,  the  morning  dose  on  the  well  day  may  be  omitted, 
while  the  others  are  continued  as  before  for  a  whole  week.  After  this 
four  capsules  should  be  taken  every  day  for  six  weeks,  the  number  being 
increased  to  six  capsules  on  the  seventh,  fourteenth,  twenty-first,  and 
twenty-eighth  days. 

In  quartan  attacks  the  same  treatment  should  be  pursued,  the 
only  difference  being  that  a  dose  of  these  capsules  should  be  given 
early  in  the  morning,  and  repeated  at  two-hour  intervals  for  three  doses, 
the  last  dose  being  an  hour  before  the  expected  paroxysm,  which  usu- 
ally occurs  in  the  afternoon.  It  should  be  remembered  that  both  for 
the  tertian  and  quartan  varieties  the  infection  is  not  got  rid  of  in  less 
than  three  months,  if  not  longer.  Prophylactic  doses,  therefore, 
amounting  to  from  6  to  9  gr.  of  quinin  daily,  should  be  continued,  with 


MALARIA  2 1 5 

the  addition  of  3  gr.  more  on  the  morning  of  the  seventh,  fourteenth, 
and  twenty-first  days,  the  only  modification  being  that  one  dose  may 
be  omitted  if  it  produces  the  characteristic  ringing  of  the  ears.  The 
reasons  for  this  prolonged  treatment  after  a  malarial  infection  are  that 
for  weeks  after  the  first  developed  attack  a  great  increase  in  the 
excretion  of  urea,  occasionally  amounting  to  three  or  four  times  the 
excretion  of  urea  at  any  other  hour,  occurs  at  the  time  of  the  original 
paroxysm,  showing  the  infection  is  still  working  in  the  s}-stem,  though 
it  may  not  be  enough  to  produce  an  attack  of  chills  and  fever. 

These  measures,  however,  do  not  suffice  for  that  most  serious  of  all 
malarial  infection  due  to  the  estivo-autumnal  parasite,  which  fre- 
quently resists  the  heaviest  doses  of  either  quinin  or  Warburg's 
tincture.  Treatment  by  arsenic  also  frequently  proves  equally  ineffi- 
cacious. Arsenic  when  administered  against  malaria  acts  on  a  wholly 
different  principle  from  quinin.  It  does  not  break  the  parox>'sms  at 
once;  rather,  its  operation  is  gradual,  and  plainly  operates  through  its 
being  a  constitutional  poison  to  the  malarial  parasite;  its  good  effects 
appearing  only  gradually,  somewhat  in  the  same  fashion  as  mercury 
acts  against  the  spirochete  of  syphilis.  The  dosage  of  arsenic  is 
regulated  altogether  by  its  effects  upon  the  stomach,  for,  Hke  other 
constitutional  remedies,  it  fails  as  soon  as  it  produces  symptoms  of  its 
own,  such  as  epigastric  uneasiness  or  pain.  The  arsenic  may  be  ad- 
ministered either  in  its  Hquid  form  of  Fowler's  solution,  or  in  a  com- 
bination with  quinin,  as  the  arsenite  of  soda,  in  doses  of  from  ^  to 

A  good  illustration  of  the  inefficacy  of  all  measures  previously 
recommended  in  the  treatment  of  serious  infection  by  the  estivo- 
autumnal  parasite  was  furnished  at  the  Roosevelt  Hospital  in  the  cases 
of  61  American  soldiers  returning  from  the  campaign  in  Cuba  during 
the  Spanish- American  War  of  1898.  The  duration  of  their  illness  be- 
fore coming  to  the  Roosevelt  Hospital  on  August  17  th  had  ranged  from 
twenty  to  forty  days.  In  all  instances  they  had  been  treated  first 
with  quinin,  and  in  a  large  proportion  this  had  been  supplemented 
by  free  dosing  with  Warburg's  tincture  and  with  arsenic. 

Subsequent  to  September  ist  and  extending  to  October  20th,  39 
additional  cases  were  admitted,  making  100  in  all,  besides  a  group  of 
mixed  malarial  and  typhoid  cases.  Of  this  list,  63  were  actively  febrile, 
the  temperature  ranging  from  103°  to  107°  F.  Of  these,  40  per  cent, 
had  chills,  with  the  usual  succession  of  symptoms,  but  with  true  inter- 
missions in  only  10  per  cent.  The  chills  were  irregular  rather  than 
periodic  in  the  remaining  30  per  cent.     They  seemed  in  some  cases 


2l6  CLINICAL  MEDICINE 

to  be  double  tertian,  and  some  double  quartan,  but  it  was  difficult  to 
settle  this  fact  conclusively  in  any  of  them,  as  the  paroxysms  of  rigors 
were  very  irregular.  The  remaining  60  per  cent,  of  the  febrile  cases 
had  no  chills,  and  the  course  of  the  fever  in  them  was  very  variable, 
the  temperature  range  rising  and  faUing  with  such  irregularity  that  the 
curves  on  the  charts  were  in  this  respect  characteristic  of  the  affection, 
and  in  marked  contrast  to  those  of  typhoid  fever. 

The  Plasmodium  malariae  was  found  in  90  per  cent,  of  all  the  cases; 
in  some,  however,  not  until  after  repeated  examinations.  The  com- 
monest forms  were  crescentic.  Some  patients  showed  relatively  large 
crescents,  and  some  small.  These  crescents  were  often  very  numerous, 
occasionally  markedly  so,  in  groups  of  patients  who  had  been  admitted 
together,  as  if  they  had  been  equally  exposed  to  the  same  infection. 
Besides  the  crescents,  there  were  many  actively  motile  extracellular 
bodies  visible,  which  were  very  small  and  round  in  contour.  Masses 
of  free  pigment  were  often  seen  in  the  field  as  well  as  in  the  white 
corpuscles.  Only  one  definite  separate  flagellum  was  detected,  but 
more  might  have  been  found  but  for  press  of  time. 

In  their  clinical  features  the  most  pronounced  effect  on  the  patients 
was  anemia,  with  emaciation,  often  extreme.  The  impoverishment 
of  the  blood  seemed  to  be  progressive,  for  it  continued  in  many  of  the 
febrile  cases  much  as  ic  does  in  patients  with  pernicious  anemia,  without 
febrile  paroxysms.  The  anemia  also  appeared  to  be  quite  independent 
of  the  enlargement  of  the  liver  or  spleen.  The  liver  was  noted  as 
enlarged  in  not  more  than  5  per  cent.  The  spleen  was  enlarged  in 
about  50  per  cent. 

In  the  majority  of  the  patients  when  they  were  running  an  actively 
febrile  temperature  there  was  no  dehrium,  but  instead  a  characteristic 
taciturnity,  all  questions  being  answered  correctly,  but  slowly  and  in 
monosyllables,  the  patients  remaining  wholly  apathetic  and  indifferent 
to  their  surroundings.  It  was  upon  this  particular  symptom  that 
the  effect  of  a  special  medicinal  treatment,  to  be  mentioned  presently, 
was  most  marked. 

After  admission  to  the  hospital  some  65  of  these  patients  were 
treated  for  fourteen  days  by  careful  feeding  and  nursing,  in  hopes  that 
the  change  from  camp  and  transport  conditions  would  of  itself  be 
beneficial,  and,  along  with  this,  quinin  In  doses  of  from  40  to  60  gr. 
a  day  were  administered,  or  Warburg's  tincture  in  ^-oz.  doses  three 
times  a  day,  while  others  were  treated  with  arsenic  either  alone  or 
added  to  the  other  drugs.  The  general  results  had  been  unsatisfactory. 
In  some  cases  the  quinin  held  the  temperature  for  a  few  days,  but  only 


MALARIA  217 

to  be  followed  by  relapses.  Its  best  results  were  in  the  small  num- 
ber of  patients  who  showed  periodic  remissions.  Warburg's  tincture 
seemed  to  be  more  successful  than  quinin,  but  arsenic,  though  pushed 
to  the  production  of  digestive  disturbances,  appeared  to  be  of  very- 
doubtful  effect.  Cold  baths  were  used  with  6  patients  with  high  tem- 
peratures, but  they  did  not  bear  them  well.  The  course  of  the  fever 
not  being  modified  thereby,  the  baths  were  abandoned. 

The  report  of  this  experience  of  two  weeks  in  the  management 
of  these  patients  led  me  to  try  a  modification  of  treatment  as  fol- 
lows: 15  gr.  of  quinin  with  15  gr.  of  powdered  ginger  were  administered 
twice  a  day — once  in  the  forenoon  and  once  in  the  afternoon — with  | 
oz.  of  the  camphorated  tincture  of  opium,  and  a  like  dose  of  the  latter 
without  quinin  at  10  p.  m.  An  oimce  and  one-half  of  paregoric,  equal 
to  3  to  3!  gr.  of  opium,  was  thus  taken  daily.  All  the  patients  with 
whom  this  was  first  tried,  47  in  number,  were  actively  febrile,  84  per 
cent,  of  them  severely  so.  In  order,  however,  to  test  comparatively 
the  effect  of  this  medication,  14  febrile  cases,  of  whom  65  per  cent, 
were  severe,  were  treated  with  Warburg's  tincture  alone  as  controls. 

The  results  were  as  follows:  In  22,  or  46  per  cent.,  of  the  number  who 
took  paregoric  the  result  was  an  immediate  break  in  the  fever,  that  is, 
the  temperature  fell  to  normal  within  twenty-four  hours,  nor  did  it 
rise  again  afterward.  This  effect  was  the  more  impressive  because  in 
every  instance  they  had  been  unavailingly  treated  for  an  average  period 
of  ten  days  previously  without  reducing  the  fever.  The  treatment  was 
then  continued  from  seven  to  fourteen  days,  when  the  men  were  dis- 
charged. Under  this  head  of  reduction  of  temperature  in  twenty-four 
hours  were  5  patients  who  had  been  treated  exclusively  by  large  doses 
of  Warburg's  tincture  without  its  affecting  the  temperature.  Of  the 
remaining  25  out  of  the  47  there  were  10  patients,  or  about  21  per 
cent.,  in  whom  it  took  from  thirty-six  to  forty-eight  hours  to  reduce  the 
temperature  to  normal.  Of  the  remaining  15,  there  were  3  in  whom 
this  treatment  failed  to  control  the  temperature.  One  of  these  had  a 
severe  chronic  colitis,  to  which  his  moderate  but  long-continued  fever 
seemed  to  be  mainly  due. 

No  relapse  was  recorded  in  any  patient  who  took  the  paregoric 
treatment  after  the  temperature  was  once  reduced  to  normal.  In 
I  case  it  took  three  days  before  the  temperature  became  normal; 
previously  the  patient  had  not  been  affected  by  Warburg's  tincture. 
In  5  cases,  or  10.6  per  cent.,  the  paregoric  treatment  could  not  be  con- 
tinued on  account  of  its  causing  nausea.  These  patients  were  then 
treated  by  the  above  doses  of  quinin  and  ginger  alone,  with  a  relatively 


2l8  CLINICAL   MEDICINE 

slow  recovery,  except  in  i  case,  which  soon  yielded  to  a  third  dose 
added  to  the  usual  prescription. 

The  experience  of  the  British  Government  in  India  upon  a  very 
large  scale  shows  that  the  administration  of  opium  is  one  of  the 
most  certain  remedies  against  malaria  in  the  tropics,  and  this  is  now 
pretty  well  settled,  as  Sir  William  Roberts  demonstrated,  by  the 
presence  in  opium  of  an  alkaloid  misnamed  narcotin,  and  which  should 
be  called  anarcotin,  owing  to  the  entire  absence  in  it  of  narcotic  prop- 
erties. The  proportion  of  the  two  alkaloids  in  Smyrna  opium  are 
morphin  8  per  cent.,  anarcotin  2  per  cent.,  while  in  Bengal  or  India 
opium  the  proportion  is  morphin  4  per  cent,  and  anarcotin  6  per  cent. 
I  chose  paregoric  on  account  of  its  containing  camphor  and  other  stimu- 
lants which  are  not  to  be  omitted  in  the  treatment  of  a  serious  malarial 
infection. 

In  the  neighborhood  of  New  York  I  have  also  met  with  cases  in 
which  the  usual  treatment  with  quinin  was  quite  inefficacious,  but 
which  yielded  to  doses  of  anarcotin  not  exceeding  1 2  gr.  a  day.  Some 
eminent  authors  speak  as  if  quinin  were  a  specific  for  every  case  of 
malarial  infection,  and  that  a  practitioner  who  failed  to  cure  by  quinin 
should  be  read  out  of  the  profession.  In  my  own  opinion  the  authors 
of  such  statements  only  show  that  their  knowledge  of  malaria  is  limited. 

YELLOW  FEVER 

This  disease  of  American  origin  has  never  prevailed  in  Asia,  but 
in  the  regions  which  it  invades  it  is  historically  one  of  the  most  fatal 
of  epidemics.  In  1790  it  destroyed  one-tenth  of  the  inhabitants  of 
Philadelphia.  My  own  medical  life  began  with  yellow  fever,  when  I 
was  appointed  physician  to  the  New  York  Quarantine  in  the  year 
1858,  and  my  experience  then  fully  illustrated  why  there  was  such  an 
uncertainty  as  to  the  nature  of  the  disease.  In  that  year  the  U.  S. 
Frigate  Susquehanna  entered  New  York  harbor  with  a  severe  epi- 
demic of  yellow  fever  on  board.  All  the  officers  and  crew  were  landed 
at  the  quarantine,  and  the  sick  taken  to  the  quarantine  hospital.  The 
frigate  was  then  fumigated  with  the  best  of  all  such  agents,  wood 
smoke,  because  wood  smoke  contains  finely  divided  particles  of  fresh 
charcoal  with  acetic  and  carbolic  acids.  Two  men  from  the  shore, 
neither  of  whom  were  immune,  were  left  in  charge  of  the  vessel,  where 
they  remained  for  two  weeks.  One  afternoon  a  thunder-shower  caused 
these  men  to  go  below  deck,  and  they  broke  into  the  gun  room,  which 
had  not  been  reached  by  the  smoke,  and  where  the  liquors  were  stored. 
In  seventy  hours  thereafter  both  men  were  taken  with  yellow  fever. 


YELLOW    FEVER  219 

Meantime,  not  one  of  the  sick  gave  yellow  fever  to  either  physicians  or 
nurses  of  the  hospital,  and  such  has  been  the  history  of  the  hospital 
for  fifty  years.  But,  however  numerous  the  cases  which  were  ad- 
mitted with  yellow  fever,  no  hospital  attendant  ever  contracted  the 
disease.  On  the  other  hand,  I  declined  the  lucrative  office  of  deputy 
health  officer,  because  every  such  officer  had  contracted  yellow  fever, 
though  he  had  nothing  to  do  with  the  patients,  but  simply  boarded 
the  ships  to  inspect  them.  These  facts  seemed  to  point  conclusively 
to  yellow  fever  clinging  to  inanimate  objects,  like  the  hold  of  a  ship. 
It  was  naturally  supposed,  therefore,  that  everything  in  a  ship  might 
become  a  carrier  of  the  disease,  such  as  articles  of  clothing,  either  of 
wools,  or  especially  of  silk,  and  I  decKned  presents  of  cigars  from  cap- 
tains of  Havana  ships  from  fear  of  the  silk  ribbons  about  the  bunches. 
All  articles  of  clothing,  therefore,  that  were  valuable  were  wheeled  into 
iron  ovens,  where  they  were  subjected  to  a  degree  of  dry  heat  supposed 
to  destroy  any  infection.  Other  articles  were  collected  into  a  large 
iron  scow,  which  every  night  was  towed  down  into  the  lower  bay  and 
its  contents  burned.  Meantime,  the  clothing  of  the  sick  was  furnished 
by  the  hospital.  So  far,  experience  demonstrated  that  yellow  fever 
was  not  in  the  least  contagious  any  more  than  ague.  But  there  were 
other  facts  about  the  infection  which  were  of  special  interest,  the  first 
being  that  it  was  a  delicate  organism  which  could  not  stand  the  frost, 
and  infected  ships  were  even  sent  north  where  they  would  encounter 
cold  weather.  Another  fact  was  that  the  disease  clung  to  seaports  or 
rivers  and  did  not  ascend  any  mountain-ranges,  but  beyond  this 
nothing  was  certain. 

The  germ  theory  of  disease  was  not  yet  even  broached,  the  word 
"bacterium"  was  not  heard  of,  all  of  which  illustrates  how  impossible 
it  was  then  to  know  anything  about  infectious  diseases  except  their 
clinical  manifestations.  We  now  know  that  yellow  fever  was  due  alone 
to  a  kind  of  mosquito,  called  the  "stegomyia."  This  mosquito  has 
its  own  habits  of  Kfe,  which  explain  why  it  was  for  so  long  unsuspected 
of  harm.  In  the  first  place  it  is  very  domestic,  and  is  not  found  in 
the  street  nor  out  of  doors,  but  breeds  wherever  it  can  find  little 
receptacles  of  water,  such  as  tin  cans,  basins,  and  pails.  It  was  by  deal- 
ing directly  with  these  domestic  utensils  that  Colonel  Gorgas  destroyed 
these  mosquitoes  in  Havana,  and  changed  that  city  from  being  the 
source  of  danger  to  every  American  city  during  the  summer  months, 
because  Havana,  under  his  administration  became  free  from  any  case 
of  yellow  fever  for  a  whole  year,  a  feat  which  Colonel  Gorgas  has  re- 
peated in  the  Panama  Zone. 


220  CLINICAL  MEDICINE 

Like  malaria,  yellow  fever  can  be  transmitted  from  person  to  per- 
son by  injection  of  the  infected  blood,  but,  wholly  unlike  malaria,  its 
virus  can  pass  through  a  porcelain  filter  and  then  transmit  the  disease 
as  actively  as  ever,  which  shows  that  this  specific  and  active  form  of 
life  is  ultramicroscopic.  This  feature  is  not  without  its  bearing  upon 
the  question  of  what  life  itself  is. 

The  facts  connected  with  the  nature  of  this  disease  were  not  estab- 
lished without  a  great  deal  of  patient  and  widespread  labor,  marked 
by  the  unselfish  devotion  of  medical  men,  some  of  whom  sacrificed 
their  Hves  in  this  dangerous  investigation.  First  in  time  came  the 
origin  and  rise  of  the  great  science  of  bacteriology,  and  hence  it  was 
natural  that  one  form  of  bacterium  after  another  was  supposed  by 
different  observers  to  be  the  cause  of  yellow  fever.  In  this  search 
Surgeon-general  Sternburg,  of  the  United  States  Army,  bore  a  dis- 
tinguished part,  and  it  was  largely  due  to  him  that  the  supposed  con- 
nection with  bacteria  was  disproved.  Moreover,  the  search  for  some 
protozoan  or  animal  parasite  similar  to  the  protozoan  that  infests  us  in 
malaria,  and  also  cattle  in  different  diseases  was  equally  unsuccessful. 
There  can  be  little  doubt  that  the  yellow  fever  agent  is  a  protozoan, 
though  it  shows  one  feature  usually  restricted  to  bacterial  diseases, 
namely,  that  one  attack,  as  a  rule,  confers  permanent  immunity  against 
the  second  attack. 

The  mosquito  after  it  has  bitten  an  infected  person  cannot  trans- 
mit the  disease  for  twelve  days,  but  after  that  may  be  infective  for 
fifty-seven  days  or  as  long  as  it  Hves.  The  incubation  period  of  human 
beings  after  infection  is  from  forty-one  hours  to  five  days  and  seventeen 
hours. 

Symptoms. — In  the  majority  no  premonitory  symptoms  may  occur, 
or  may  be  confined  to  headaches  or  pains  throughout  the  body. 
The  onset  is  frequently  with  rigors,  the  temperature  rapidly  rising  to 
102°  or  above  106°  F.,  the  face  generally  suffused,  the  conjunctivas  being 
injected,  and  there  may  be  considerable  photophobia  with  severe 
backache  and  pains  in  the  limbs.  The  urine  is  diminished  in  quantity, 
but  not  albuminous.  An  early  symptom  is  distress,  often  with  pain 
at  the  epigastrium.  These  symptoms  continue  during  the  second  day, 
to  which  may  be  added  a  yellowish  tinge  to  the  eyeballs.  Vomiting 
may  set  in  at  this  stage,  but  consists  only  of  the  contents  of  the  stomach. 
By  the  third  day  the  symptoms  may  vary  according  to  the  severity  of 
the  attack.  In  bad  cases  the  temperature  begins  to  fall,  even  below 
normal,  to  be  succeeded  by  the  very  ominous  development  of  black 
vomit.     This  at  first  consists  of  black  specks  in  the  ejecta,  but  after- 


TETANUS  221 

ward  its  color  fully  justifies  the  term  "black  vomit."  Severe  pains 
may  take  place  in  the  abdomen,  and  then  by  the  fifth  day  general 
jaundice  is  the  dominant  feature.  The  temperature  at  this  time  may 
rise,  again  to  be  followed  by  an  irregular  fall.  Along  with  the  cramps 
in  the  abdomen  and  the  black  vomit,  tarry  discharges  may  follow  from 
the  bowels.  By  this  time  the  signs  of  general  prostration  become 
extreme,  and  may  be  accompanied  by  hiccup,  dehrium,  convulsions, 
coma,  and  death.  In  all  severe  cases  a  characteristic  fall  in  the  pulse 
compared  with  the  temperature  takes  place,  the  pulse  falhng  to  70,  60, 
or  50  per  minute.  In  this  disease,  as  in  other  infections,  there  is  a  great 
variation  between  different  individuals  in  the  severity  of  the  attacks, 
some  even  being  but  shghtly  ill,  while  others  in  the  same  house  rapidly 
succumb  to  black  vomit  and  its  attendant  symptoms.  These  milder 
cases  are  a  little  more  likely  to  experience  a  second  attack  than  those 
who  recover  from  the  severer  forms  of  development. 

Changes  in  the  heart  are  not  specific,  and  are  similar  to  those  occur- 
ring in  bad  intoxications  by  other  agents.  The  stomach  presents  more 
or  less  hyperemia  of  the  mucosa  with  catarrhal  swelling,  and  contains 
the  material  which  ejected  during  Ufe  is  known  as  the  black  vomit. 
There  is  often  general  glandular  enlargement,  in  which  the  cervical  and 
mesenteric  groups  are  most  involved.  The  Hver  is  usually  of  a  pale- 
yellow  or  brownish-yellow  color,  with  its  cells  in  various  states  of  fatty 
degeneration.     The  kidneys  always  show  traces  of  diffuse  nephritis. 

Treatment. — As  might  be  expected,  treatment  is  of  very  little  avail 
in  this  specific  disease  and  should  be  simply  symptomatic.  At  the 
beginning  a  large  dose  of  castor  oil  of  from  i  to  2  oz.  may  be  tried,  and 
after  this  rectal  irrigation  with  normal  saline  of  from  i  to  2  gallons  at 
a  time.  The  fever,  however,  should  be  combated  with  a  cold  bath, 
as  in  the  treatment  of  typhoid  fever.  When  the  heart  begins  to  fail, 
the  only  remedy  is  by  hypodermic  injections  of  7  gr.  of  camphor  in 
sterilized  almond  or  olive  oil,  to  be  repeated  every  two  or  three  hours. 
A  proper  antiserum  treatment  for  yellow  fever  has  not  yet  been  found. 

Due  to  the  progress  of  medical  science,  this  once  formidable  epi- 
demic disease  is  now  well-nigh  extinct. 

TETANUS 

The  pathology  of  tetanus  was  the  subject  of  my  first  pubKcation 
in  the  year  1861.  I  had  then  lost  a  horse  belonging  to  the  New  York 
Quarantine,  who  died  from  tetanus,  and  on  looking  up  the  literature  I 
found  that  the  greater  number  of  authors  at  that  time  pronounced  tet- 
anus to  be  due  to  the  puncture  or  bruising  of  a  peripheral  nerve.   What 


22  2  CLINICAL  MEDICINE 

causes  a  nerve  so  injured  to  produce  tetanus  a  leading  medical  author- 
ity, Watson,  then  said  was  the  mystery.  On  inquiry,  I  found  that 
there  was  a  whole  district  on  Staten  Island  where  tetanus  was  endemic, 
so  that  horses  and  calves  which  were  to  be  gelded  had  to  be  sent  away 
from  that  district,  because  otherwise  they  would  inevitably  succumb 
to  tetanus.  Further  inquiries  showed  that  a  similar  region  where 
tetanus  was  endemic  was  on  the  shores  of  Long  Island  Sound,  and  that 
in  both  cases,  namely,  Staten  Island  and  Connecticut,  the  land  was 
manured  by  fish  called  "moss-bunkers."  These  facts  at  once  demon- 
strated the  improbability  of  injury  of  peripheral  nerves  occurring  epi- 
demically in  a  restricted  area,  and  made  it  much  more  likely  that 
tetanus  was  due  to  a  poison  in  the  blood  similar  in  its  effects  to  that  of 
strychnin.  The  analogies  between  poisoning  by  strychnin  and  tetanus 
are  numerous.  In  both,  the  chief  clinical  feature  is  tetanic  spasm  of 
the  muscles,  accompanied  by  excessive  reflex  excitabiUty  of  the  surface 
nerves.  An  animal  poisoned  by  strychnin  remains  free  from  the  con- 
vulsions so  long  as  it  is  not  touched,  but  the  lightest  application  to  the 
skin  or  even  a  breath  of  air  throws  it  into  convulsions.  Similarly,  a 
patient  with  tetanus  must  be  kept  absolutely  quiet,  for  both  a  draft 
of  air  or  even  a  sudden  light  will  bring  on  the  general  spasms.  The 
differences  between  strychnin-  and  tetanus-poisoning  are  sufficient  to  be 
clearly  demonstrated,  as  they  have  been  in  medicolegal  trials.  Strych- 
nin does  not  produce  lock-jaw,  and  the  muscles  relax  after  the  spasm, 
while  in  tetanus  the  tonic  contractions  persist,  marked  by  exacerbations 
of  the  spasm  from  time  to  time. 

The  actual  demonstration  that  tetanus  is  caused  by  a  specific 
bacterium  was  really  made  by  Nicolaier  in  1885,  but  it  was  not  isolated 
from  the  pus  or  discharges  from  the  wound  until  accomplished  by 
Kitasato  in  1889.  Knud  Faber,  in  1890,  was  the  first  to  demonstrate 
that  all  the  symptoms  of  tetanus  could  be  produced  by  injection  of 
its  toxin  into  the  blood  without  any  of  its  bacteria.  This  led  finally 
to  the  demonstration  that  the  tetanus  bacilli  are  Hmited  to  the  seat 
in  the  body  where  they  were  first  inoculated,  and  that  they  are  not  to 
be  found  in  any  other  situation.  This  is  probably  the  only  example  of 
the  kind  in  pathology.  In  other  diseases  the  bacteria  which  cause  them 
are  disseminated  everywhere,  but  in  tetanus  the  causes  of  the  infection 
always  remain  local,  and  they  are  its  absorbed  toxins  and  not  the  bacilli 
themselves  which  produce  the  fatal  result.  The  practical  importance 
of  this  is  insisted  upon  by  Moscowitz,  who  advises  that  the  seat  of  the 
inoculation  of  the  bacilli  should  be  cut  out  in  order  to  prevent  the  for- 
mation of  any  more  toxins  there.     "Bacillus  tetani"  is  a  slender  rod 


TETANUS  223 

which  may  grow  into  long  threads,  one  end  of  which  is  often  swollen 
and  occupied  by  a  spore.  The  spores  are  very  resistant  to  a  great 
variety  of  disinfectants,  such  as  carbolic  acid,  corrosive  subhmate,  and 
heat,  and  these  are  the  facts  which  demonstrate  the  dangers  due  to 
the  wide  distribution  in  nature  of  this  deadly  agent,  which  has  been 
found  to  penetrate  fully  6  feet  beneath  the  surface  of  the  ground.  The 
tetanus  bacillus  is  especially  abundant  in  garden  earth,  particularly 
where  horse  manure  has  been  used,  foj  it  is  said  that  this  bacillus  exists 
normally  in  the  intestines  of  the  horse.  Hence  it  is  much  more  apt  to 
infect  through  injuries  of  the  foot,  such  as  by  treading  upon  a  nail,  than 
in  injuries  of  the  upper  extremities.  Still  it  has  been  known  to  follow 
upon  infection  of  mere  scratches  of  the  skin,  because  it  can  survive  dr}'- 
ing  for  at  least  a  number  of  days  upon  wood  sphnters. 

Like  other  bacteria,  tetanus  requires  a  period  of  incubation  after 
its  entrance  before  it  manifests  any  of  its  symptoms.  An  important 
rule  is  that  the  shorter  the  period  of  incubation,  the  worse  the  prognosis. 
The  period  of  incubation  also  is  much  shorter  in  warm  climates.  la 
temperate  climates  the  rule  is  from  one  to  twenty-two  da3^s.  I  had  a 
valued  acquaintance  who  was  a  sea  captain,  and  who,  while  loading 
guano  from  off  the  coast  of  Peru,  had  his  hand  bruised  by  a  cask  as  it 
was  being  swung  on  board.  He  died  from  tetaaus  in  less  than  twenty- 
four  hours. 

The  chief  effect  of  the  tetanus  toxin  is  that  it  reaches  the  spinal 
cord,  not  by  the  blood  nor  even  by  the  lymph,  but  proceeds  directly 
along  the  substance  of  the  nerve,  and  is  claimed  by  Tiber ti  to  be  prop- 
agated along  the  axis-cyhnder,  due  to  the  chemical  afi&nity  of  nerve- 
cells  for  the  poison. 

Great  hopes  were  entertained  on  the  announcement  that  an  anti- 
toxin for  tetanus  had  been  discovered  by  Kitasato  and  Behring,  but, 
unfortunately,  tetanus  antitoxin  has  proved  almost  wholly  without 
efficacy  in  the  treatment  of  human  tetanus ;  so  different  from  the  marked 
success  of  the  antitoxin  of  diphtheria  in  the  treatment  of  that  disease. 
The  reason  for  this  unfortunate  difference  is  that  the  antitoxin  to 
diphtheria  is  administered  within  but  a  short  time  of  the  infection,  and 
that  it  is  successful  in  proportion  to  its  very  early  use;  but  in  the  case 
of  tetanus  antitoxin  the  disease  has  already  been  incubating  for  a 
number  of  days,  if  not  weeks,  before  we  know  that  tetanus  is  impending. 
This  does  not,  however,  mihtate  against  the  use  of  this  antitoxin  as  a 
prophylactic  to  be  employed  when  a  person  has  received  what  may  be 
feared  as  an  injection  of  tetanus  toxin  through  pus  from  the  wound  of 
a  tetanus  patient,  or  through  an  infection  of  garden  earth. 


224  CLINICAL  MEDICINE 

We  read  of  so-called  idiopathic  tetanus  because  no  discoverable 
source  or  internal  lesion  can  be  identified  as  the  seat  of  the  infection. 
I  treated  a  patient  once  whose  only  trouble  was  a  chronic  discharge 
from  his  right  ear.  In  him  all  of  the  ordinary  accompaniments  of  the 
disease  were  strikingly  manifested,  and  he  had  to  be  constantly  watched 
lest  the  spasm  come  on  in  the  muscles  of  the  back  and  of  the  extremities, 
which  would  throw  him  out  of  bed,  using  his  left  heel  as  the  pivot  for 
his  movements.  He  finally  recovered  under  doses  of  potassium  bromid 
amounting  to  480  gr.  a  day  for  three  days,  and  gradually  diminishing 
these  doses  for  a  week  afterward. 

The  incubation  period  varies  very  much  according  to  the  cHmate, 
being  much  shorter  in  hot  than  in  temperate  climates. 

Symptoms. — In  many  cases  there  are  prodromal  symptoms  for 
several  days  to  a  week,  during  which  the  patient  is  much  disturbed  in 
his  sleep,  with  terrifying  dreams;  the  earhest  symptoms  are  those  with 
stiffness  about  the  neck,  with  gradually  increasing  difficulty  in  opening 
the  mouth,  until  finally  trismus  or  lock-jaw  is  fully  developed.  This 
may  be  so  extreme  that  teeth  have  been  removed  in  order  to  allow  liquid 
food  to  be  passed  in  a  tube  over  the  tongue.  Next  in  order  comes 
tetanic  spasm  of  the  muscles  of  the  back,  and  then  of  the  extremities. 
Previous  to  that  the  muscles  of  the  front  of  the  abdomen  become  rigid, 
and  an  acute  pain  occurs  from  spasm  of  the  diaphragm,  beginning  in 
front  and  passing  co  the  back.  The  affected  muscles  never  wholly 
relax,  but  every  now  and  then  tetanic  spasms  in  them  are  aggravated 
by  paroxysms  of  severe  muscular  contractions,  which  are  sometimes 
terrific  in  their  character,  the  rectus  abdominis  being  found  ruptured 
after  death,  and  not  infrequently  the  bones  are  fractured  at  the  seat 
of  the  muscular  attachments.  Meanwhile  the  muscles  of  the  face  are 
affected,  and  the  edges  of  the  mouth  are  drawn  down,  causing  an  expres- 
sion named  "risus  sardonicus."  As  the  muscles  of  the  back  become 
involved  along  with  those  of  the  leg,  the  whole  body  may  be  arched 
backward,  so  that  it  rests  upon  the  occiput  and  the  heel,  to  which 
condition  the  term  "opisthotonos"  has  been  given.  When  the  muscles 
in  the  front  of  the  abdomen  are  most  affected,  the  body  is  bent  forward, 
hence  the  term  "emprosthotonos,"  but  if  the  muscles  are  more  affected 
on  one  side  than  on  the  other,  the  body  is  correspondingly  turned,  and 
the  patient  is  said  to  have  "pleurosthotonos."  In  severe  cases  the 
patient  may  die  between  the  first  twenty-four  hours  and  three  days, 
the  variations  being  from  ten  days  to  three  weeks  in  chronic  cases. 
When  recovery  takes  place  it  is  always  gradual,  and  more  or  less  tm- 
natural  stiffness  remains  for  a  long  time  in  the  affected  muscles. 


HYDROPHOBIA 


225 


Death  sometimes  occurs  from  actual  asphyxia  due  to  the  arrest  of  the 
respiratory  movements  of  the  thorax.  Meanwhile,  as  has  already 
been  mentioned,  the  reflex  excitabihty  of  the  nerves  is  extraordinarily 
heightened. 

Treatment. — The  severe  spasms  can  always  be  relaxed  by  the  ad- 
ministration of  chloroform,  but  the  effects  of  this  drug  upoQ  the  rest 
of  the  system  in  the  degeneration  of  both  heart  and  kidney  forbids 
its  too  continuous  use.  One  of  the  greatest  agents  at  our  command 
for  reduction  of  the  reflex  excitability  is  potassium  bromid,  but  to  be 
effective  its  administration  should  always  be  pushed  to  the  extent  of 
an  ounce  a  day,  while  the  further  treatment  should  consist  of  as  ab- 
solute an  avoidance  of  exciting  causes  as  is  possible,  hence  the  patient 
should  be  kept  in  a  dark  room,  and  ever}'  movement,  either  external  or 
internal,  as  far  as  practicable,  avoided.  The  pain  should  be  reheved  by 
hypodermics  of  morphin,  and  against  the  great  exhaustion  produced  by 
the  disease  the  patient  should  be  fed  with  peptonized  milk  and  nourish- 
ing broths. 

HYDROPHOBIA 

Historically,  this  disease  has  been  known  from  remote  times.  De- 
mocritus,  of  Abdera  (500  b.  c),  describes  it  and  also  speaks  of  it  as 
affecting  certain  groups  of  muscles  with  spasms  like  tetanus.  After 
him  it  is  described  by  Aristotle  and  other  physicians  of  classical  times. 
Galen  (a.  d.  131)  speaks  of  it  as  the  worst  of  diseases.  It  was  early 
ascribed  to  the  bite  of  a  dog,  and  the  poet  Horace  mentions  its  prev- 
alence at  the  time  of  the  rise  of  the  Dog  Star  (Sirius). 

Through  the  Middle  Ages  it  was  very  prevalent  in  all  European 
countries,  but  of  late  has  almost  disappeared  from  north  Germany 
and  Britain,  due  to  the  enforcements  of  dog-muzzling  ordinances. 
It  occurs  widely  in  the  United  States,  and,  owing  to  this  fact,  American 
physicians  have  been  able  to  confirm  the  discovery  in  1903  by  Negri 
of  its  active  agent,  so  that  the  diagnosis  of  rabies  can  now  be  established 
at  once  by  finding  the  Negri  bodies  in  a  dog's  brain  without  waiting, 
it  may  be  for  weeks,  for  the  development  of  the  disease  in  experiment- 
ally inoculated  animals. 

The  Negri  bodies  are  found  included  in  the  cytoplasm  of  the  nerve- 
cells.  They  are  described  as  rounded  or  oval  in  form,  having  a  homo- 
geneous oxyphil  "ground  substance,"  containing  a  central  body  sur- 
rounded by  granules.  These  bodies  vary  in  shape  and  size  from  0.5 
to  20  mm.  in  diameter,  and  are  present  in  almost  all  the  nerve-cells  in 
the  central  nervous  system.  They  are  certainly  not  bacteria,  but  pro- 
tozoa instead.     Owing  to  their  having  no  cell  wall  and  being  very  plas- 

]5 


226  CLINICAL  MEDICINE 

tic,  they  can  be  so  minutely  divided  that  they  can  pass  through  the 
pores  of  a  Berkefeld  filter.  It  was  from  this  fact  that  the  virus  of  hy- 
drophobia was  for  so  long  unidentified  and  classed  among  the  ultra- 
microscopic  filterable  viruses.  Absorption  of  this  rabic  poison  may 
take  place  even  from  a  healthy  mucous  surface,  such  as  the  conjunctiva 
and  nasal  mucous  membrane,  as  shown  in  experiments  on  animals. 

Apparently,  all  warm-blooded  animals  are  capable  of  contracting 
hydrophobia,  including  cows  and  horses.  In  Syria  I  found  it  very 
prevalent,  where  cats  often  communicate  it.  Well-authenticated  cases, 
both  there  and  in  Europe,  name  the  wolf  as  subject  to  it,  and  also 
the  hyena.  A  physician  related  to  me  the  case  of  a  man  who  died 
from  hydrophobia,  who  insisted  that  he  contracted  the  disease  from  a 
rat  which  attacked  him  and  bit  his  fingers. 

The  incubation  period,  according  to  some  statements,  may  be  very 
long,  but  probably  the  average  ranges  between  twenty  and  sixty  days. 
The  variations  depend  mostly  upon  the  part  of  the  body  bitten,  those 
about  the  face  in  children  being  the  shortest.  "At  the  end  of  the  in- 
cubation period  the  wound  (which  may  before  have  appeared  healed) 
becomes  uncomfortable,  there  is  itching,  tingling,  and  a  sense  of  local 
heat,  which  may  become  almost  unbearable;  this  is  usually  accompanied 
by  a  sharp  stinging  pain,  which  may  be  locahzed  or  may  follow  the 
course  of  the  nerves"  (Sims-Woodhead) . 

All  observers  agree  that  the  virus  is  propagated  by  the  nerves  from 
the  periphery  to  the  central  nervous  system,  and  .not  by  the  lymph- 
channels  or  by  the  blood-current.  In  this  it  resembles  tetanus.  The 
greater  the  number  of  surface  nerves  in  the  part  bitten,  as  in  the  face 
or  tips  of  the  fingers,  the  sooner  the  development  of  the  disease.  As 
a  rule,  however,  only  about  i6  per  cent,  of  persons  bitten  by  a  rabid 
dog  contract  the  disease,  because  the  saliva  on  the  dog's  teeth  is  apt 
to  be  wiped  off  on  the  clothing  of  the  person. 

Symptoms. — The  prodromal  symptoms  are  much  alike  in  dog  and 
man.  During  the  early  stages,  which  may  last  for  from  two  to  six 
days,  the  prodromal  symptoms  are  feverishness  and  thirst,  the  patient 
becomes  exceedingly  depressed  and  anxious,  the  muscles  of  the  face 
are  drawn  and  restless,  and  there  is  marked  pallor;  the  patient  may 
talk  freely,  but  is  constantly  taking  sighing  inspirations,  and  general 
surface  hyperesthesia  comes  on.  The  pulse  quickens  and  the  respira- 
tions are  proportionately  hurried  and  shallow.  On  the  second  or 
third  day  the  symptoms  become  more  pronounced,  the  patient  becomes 
much  more  excited;  he  wanders  about  in  a  restless  condition,  seldom 
fixing  his  eyes  on  anything,  with  suspicious  side  glances  as  though  for 


TRYPANOSOMIASIS    (SLEEPING   SICKNESS)  227 

some  hidden  danger.  The  conjunctiva,  Hke  the  mucous  membrane  of  the 
mouth,  is  markedly  congested.  In  the  latter  there  is  an  accumulation 
of  thick  tenacious  mucus,  which  he  is  anxious  to  get  rid  of.  It  is  then 
that  a  great  difficulty  in  swallowing,  especially  of  fluids,  comes  on,  but 
though  he  makes  the  most  determined  effort  to  drink,  the  moment 
the  fluid  comes  in  contact  with  the  fauces  it  is  expelled  with  violence, 
when  severe  spasmodic  contractions  of  the  muscles  of  deglutition  and 
of  ordinary  respiration  come  on,  in  which  a  general  tetanic  state 
with  marked  opisthotonos  and  a  stoppage  in  breathing  may  occur. 
In  many  cases  the  mere  sight  of  water  causes  such  terror  that  the 
patient  seeks  to  avoid  it.  At  this  stage  a  patient  often  becomes 
dehrious  with  maniacal  attacks,  during  which  he  may  try  to  kill  his 
attendants.  The  excitement  sometimes  suddenly  subsides,  because 
during  the  spasms  a  patient  may  sink  and  die.  In  other  instances, 
both  in  man  and  in  the  dog,  marked  paralytic  symptoms  show  them- 
selves in  certain  groups  of  muscles,  occasionally  taking  the  form  of 
Landry's  ascending  paralysis.  The  dread  of  this  fatal  disease  nat- 
urally may  fill  persons'  minds,  who  have  been  bitten  by  a  dog,  with 
such  apprehensions  that  they  are  attacked  with  a  form  of  maniacal 
hysteria,  in  which  they  imagine  that  they  have  the  disease,  and 
refuse  to  touch  water,  which  they  claim  brings  on  spasms  in  the  throat. 
These  cases,  however,  may  soon  be  correctly  diagnosed  as  due  to  imag- 
inary fears,  so  that  in  the  course  of  a  week  or  ten  days  the  absence  of 
the  symptoms  of  true  hydrophobia  should  lead  to  the  treatment  of  a 
patient  as  a  case  of  hysteria. 

Treatment. — There  is  no  treatment  for  this  fearful  complaint,  and 
the  best  course  is  to  keep  the  patient  continuously  under  chloroform 
and  hypodermics  of  morphin. 

TRYPANOSOMIASIS   (SLEEPING  SICKNESS) 

One  of  the  most  remarkable  instances  of  diseases  propagated  by 
inoculation  through  bites  of  insects,  similar  in  its  way  to  the  infec- 
tion by  animal  parasites  in  human  malaria,  is  the  propagation  of  try- 
panosomiasis by  the  bites  of  different  species  of  the  tsetse  fly.  The 
world  was  first  informed  of  such  infections  by  the  great  African  explorer, 
Livingstone,  who  minutely  described  the  ravages  produced  in  cattle 
and  in  horses  by  the  bite  of  a  fly,  so  that  at  that  time  precautions  were 
adopted  to  prevent  such  domestic  animals  from  entering  districts  where 
the  tsetse  fly  abounded.  Subsequent  writers  described  similar  infec- 
tion of  the  blood  of  horses  in  a  disease  called  surra,  but  it  was  not, 
however,  until  the  formidable  disease  cafled  the  sleeping  sickness 


228  CLINICAL  MEDICINE 

among  human  beings  was  recognized  as  proceeding  from  the  bites  of 
tsetse  flies  that  the  attention  of  ^vernments  was  drawn  to  the  sub- 
ject, and  scientific  investigators  were  despatched  to  districts  on  the 
west  coast  of  Africa,  where  it  was  first  known,  and  from  which  it  was 
propagated  by  the  opening  up  of  that  continent  through  the  Congo 
Basin  into  the  regions  of  Uganda  and  Rhodesia. 

Different  species  of  the  tsetse  fly  are  known  to  infect  large  game 
animals  throughout  wide  districts  of  Africa,  and  an  interesting  ques- 
tion arises  whether  the  disappearance  or  extinction  of  many  large  forms 
of  animal  life  in  past  geologic  periods  may  not  have  been  due  to  these 
same  insects,  because  tsetse  flies  have  been  found  embedded  in  the 
strata  of  the  Miocene  Period  in  Colorado;  a  not  improbable  surmise, 
considering  the  terrible  ravages  produced  by  the  sleeping  sickness  in 
Uganda  in  our  own  times. 

Like  the  mosquito  in  propagating  malaria,  it  does  not  originate 
that  disease,  but  is  simply  a  "carrier"  of  it  from  the  infected  to  the 
well,  so  the  tsetse  fly  carries  the  sleeping  sickness  only  from  animals 
or  persons  whose  blood  is  already  charged  with  the  trypanosome  para- 
site. It  has  been  surmised  that  the  blood  of  the  crocodile,  on  which  the 
fly  settles,  is  the  original  source  of  the  infection.  Numerous  varieties 
of  tsetse  flies  have  been  captured  and  kept  in  confinement  for  long  pe- 
riods, and  then  set  free  to  bite  animals  or  even  human  beings,  without 
any  subsequent  injury,  but  when  they  were  left  to  bite  the  infected  ani- 
mals an  interval  of  twenty  days  would  elapse  before  the  flies  them- 
selves became  infective.  When  they  did  so,  they  appeared  to  have 
the  power  of  infecting  for  the  rest  of  their  Hves,  some  cases  being 
reported  of  such  power  of  infecting  being  kept  for  three  years  by  a 
single  fly.  In  a  great  many  wild  animals,  though  they  are  infected, 
the  presence  of  the  parasite  in  the  blood  does  not  seem  to  occasion 
much  harm;  nevertheless  when  the  infection  is  conveyed  from  them  to 
other  species,  and  notably  to  human  bodies,  the  most  disastrous  results 
foUow. 

In  the  case  of  the  human  being  the  ordinary  mode  of  infection  has 
been  by  the  fly  called  Palpalis  gambiense,  but  lately  it  has  been  shown 
that  another  species,  called  morsitans,  is  also  capable  of  propa- 
gating the  disease,  and  it  is  a  question  whether  still  other  species 
of  this  fly  may  not  also  be  able  to  infect. 

The  parasites  of  the  different  species  of  trypanosomes  are  to  be 
found  in  the  cerebrospinal  fluid,  and  less  often  in  the  blood.  There 
can  be  httle  doubt  that  the  cycle  of  development  occurs  in  the  body  of 
the  tsetse  fly  in  a  way  very  similar  to  the  development  of  the  malarial 


KALA-AZAR  229 

parasites  in  the  body  of  the  mosquito,  though  all  of  the  stages  of  that 
development  have  not  been  worked  out.  The  blood  of  healthy  persons 
may  contain  this  parasite,  just  as  in  the  case  of  malarial  infection,  with- 
out producing  many  symptoms,  but  when  they  do,  the  disease  may  be 
clinically  described  as  consisting  of  three  stages,  preceded  by  a  period 
of  incubation  which  may  be  very  chronic.  When  the  disease  sets  in, 
however,  the  first  symptoms  are  chiefly  nervous,  the  pulse  being 
quickened  and  the  mind  becoming  lethargic,  this  lethargy  deepen- 
ing with  the  chronic  progress  of  the  disease  through  a  stage  marked 
especially  by  muscular  tremors;  and,  lastly,  by  a  profound  lethargy 
which  ends  in  death.  Among  the  names  of  some  of  the  scientific 
investigators  of  this  remarkable  disease  we  shall  mention  Koch, 
Bruce,  Nebarro,  Evans,  Todd,  Button,  and  others. 

Button  found  a  trypanosome  in  the  blood  of  a  West  Indian  in  igoi, 
hut  in  1902  Castellani  demonstrated  trypanosomes  in  the  cerebrospinal 
fluid  of  5  cases  of  the  African  sleeping  sickness. 

Treatment. — As  to  treatment,  the  results  at  first  of  the  injections 
of  atoxyl,  recommended  by  Koch,  seemed  to  be  very  promising,  but 
relapses  were  very  frequent,  and  evidently  due  to  the  larval  or  younger 
forms  of  the  infection  not  being  affected  by  this  medicinal  poison.  A 
more  serious  complication,  however,  was  that  atoxyl  in  time  produced 
total  blindness,  accompanied  by  atrophy  of  the  optic  nerve. 

More  recently  salvarsan  has  been  recommended,  from  its  known 
power  of  dealing  with  all  parasitic  protozoa,  and  already  numerous 
cases  of  actual  cures  have  been  reported  from  its  use. 

The  incubation  period  is  very  uncertain  and  may  be  prolonged. 

A  negro  boy  from  the  Congo  died  of  the  disease  at  a  training-school  at 

Colwyn  Bay,  North  Wales,  although  he  had  resided  for  three  years  in 

Wales  in  good  health  before  the  symptoms  declared  themselves.     This 

infection,  after  proceeding  up  the  Congo  Basin,  finally  entered  Uganda, 

where  it  is  estimated  that  100,000  of  the  inhabitants  died  from  it. 

The  average  duration  of  the  disease  is  about  a  year,  but  may  last  for 

eighteen  months. 

KALA-AZAR 

Our  review  of  the  diseases  infecting  the  human  race  by  means  of 
the  bites  of  insects  covered  a  truly  formidable  hst,  beginning  with  the 
bubonic  plague,  transmitted  by  fleas  which  have  bitten  sick  rats.  Then 
the  long  list  of  malarial  diseases  caused  by  the  bite  of  a  mosquito; 
yellow  fever,  caused  by  the  bite  of  another  species  of  mosquito; 
the  sleeping  sickness  of  Africa,  caused  by  the  bite  of  a  tsetse  fly;  and 
now,  lastly,  the  most  formidable  of  all,  for  its  high  percentage  of 


230  CLINICAL  MEDICINE 

death,  namely,  kala-azar,  caused  by  the  bite  of  a  bedbug.  This 
disease  prevails  most  extensively  in  the  valley  of  Assam  and  in  neigh- 
boring districts  of  eastern  India,  but  is  also  reported  from  parts  of 
China.  This  parasite  was  first  identified  by  Leishman  and  also  by 
Donovan  in  1903.  It  consists  of  oval  or  oat-shaped  bodies,  with  two 
collections  of  chromatin  granules,  appearing  on  opposite  sides  of  the 
cell. 

Symptoms. — A  great  enlargement  of  the  spleen  is  always  found, 
and  to  a  less  degree  enlargement  of  the  liver.  The  disease  begins  with 
a  high  fever,  which  is  soon  accompanied  by  the  characteristic  enlarge- 
ment of  the  spleen,  in  which  organ  the  parasite  is  found  in  immense 
numbers.  Irregular  pigmentations  of  the  skin  also  occur  in  the 
course  of  the  disease.  The  bone-marrow  is,  moreover,  invaded  by  the 
parasites,  largely  explaining  the  rapid  development  of  anemia,  which 
may  be  accompanied  by  interstitial  hemorrhages.  Owing  to  this 
anemia,  degeneration  of  all  muscular  tissues,  including  that  of  the 
heart,  occurs.  The  fever  lasts  for  several  weeks,  followed  by  apparent 
remissions,  to  end,  however,  with  a  return  of  the  fever  again,  until  the 
patient  sinks,  owing  to  the  general  blood  destruction,  its  course  being 
occasionally  shortened  by  intercurrent  comphcations.  The  mortality 
is  very  high,  so  that  it  is  doubtful  if  any  patients  recover  from  the 
infection. 

Europeans  are  but  rarely  affected,  as  they  do  not  come  in  contact 
with  the  sick.  The  only  effective  prophylactic  measures  are  to  set 
fire  to  the  infected  huts,  and  as  to  treatment,  the  only  measure  that 
is  represented  to  be  beneficial  is  by  large  doses  of  quinin,  which  are 
said  to  modify  or  to  shorten  the  febrile  attacks. 

Treatment. — Though  not  mentioned  by  authors,  salvarsan,  given 
intravenously,  might  be  tried,  owing  to  its  demonstrated  power  over 
protozoal  infections. 

ROCKY  MOUNTAIN  FEVER 

This  localized  or  endemic  disease,  which  prevails  only  in  the  moun- 
tainous regions  of  Montana  and  Idaho,  has  some  very  peculiar  fea- 
tures, one  of  which  is  its  extraordinary  severity  in  Montana,  where  the 
death-rate  is  reputed  to  be  70  per  cent,  from  it,  while  in  the  adjacent 
state  of  Idaho  the  same  disease  causes  only  2  per  cent,  of  deaths.  It 
is  agreed  by  all  investigators  that  it  is  communicated  to  man  b}^  the 
bite  of  a  tick.  It  has  been  experimentally  communicated  to  guinea- 
pigs  and  to  monkeys,  and  further,  one  attack  produces  immunity 
from  any  subsequent  infection. 


SURGICAL   INFECTIONS  23 1 

Symptoms. — Clinically,  it  goes  through  the  usual  stages  of  such 
infection  in  having  an  incubation  period  of  from  three  to  ten  days,  when 
it  then  sets  in  with  fever  rising  to  104°  and  105°  F.,  with  general  pains, 
often  accompanied  by  delirium.  The  special  feature,  however,  is  an 
eruption  which  closely  resembles  that  of  the  old  typhus  fever,  being 
macular,  and  in  many  cases  it  becomes  hemorrhagic.  It  was  unfor- 
tunate, on  that  account,  that  some  observers  actually  called  it  tj'phus. 
Typhus  fever  is  altogether  distinct  from  this  affection,  both  in  its 
origin  and  in  its  being  highly  contagious.  The  duration  of  this  Rocky 
Mountain  fever  is  ordinarily  four  weeks. 

Treatment. — As  quinin  has  proved  of  no  avail,  the  treatment  must 
be  simply  symptomatic. 

SURGICAL  INFECTIONS 

The  skin  at  all  times  swarms  with  micro-organisms,  such  as  strep- 
tococci and  staphylococci,  which  could  induce  serious  or  fatal  general 
infections  of  the  body  whenever  a  surgeon  makes  an  incision  into  it. 
When  I  first  became  a  physician  it  was  universally  believed  that  such 
infections  by  pyogenic  organisms  were  inevitable,  and,  therefore,  that 
the  formation  of  pus  after  a  surgical  operation  was  so  constant  that  the 
resultant  pus  itself  was  divided  into  such  imaginary  classes  as  laudable 
pus  and  gnmious  pus. 

It  was  Lister  who  first  demonstrated  that  no  surgical  operation 
need  be  followed  by  any  pus  if  the  surgeon  first  took  precautions  for 
disinfecting  the  skin  by  various  measures  which  he  recommended. 
At  first  he  operated  only  while  the  cutaneous  surface  was  enveloped  in 
a  cloud  of  disinfecting  spray.  Later  it  was  proved  that  this  spray 
was  unnecessary,  and  that  by  diligently  washing  the  skin  to  be  incised 
with  carbolic  acid  or  corrosive  sublimate  solutions,  but,  above  all,  by 
the  surgeon  disinfecting  his  own  fingers,  the  most  extensive  incisions 
through  the  skin  might  be  made  without  causing  any  of  the  dangerous 
infections  of  former  days.  As  it  is  difficult  thoroughly  to  steriHze  the 
fingers,  surgeons  are  now  accustomed  to  wear  sterihzed  India-rubber 
gloves  while  they  operate.  These  and  similar  measures  of  antiseptic 
surgery  have  effectually  abolished  surgical  infections. 


CHAPTER    V 

INFECTIONS  BY  THE  BACILLUS  COLI 

Modern  surgery  has  discovered  that  the  surface  of  the  skin  swarms 
with  milUons  of  micro-organisms  which  can  be  the  most  certain  causes 
of  disease  and  death,  if  once  they  could  gain  admission  through  the 
layers  of  healthy  skin.  But,  on  the  other  hand,  the  Hning  of  the  intes- 
tines swarms  with  corresponding  micro-organisms  which  could  produce 
every  variety  of  serious  infection,  if  only  they  could  find  entrance 
through  the  mucous  membrane  into  the  circulation.  Among  such 
intestinal  micro-organisms  is  the  Bacillus  coK,  long  supposed  to  be  a 
harmless  resident  of  the  intestines,  because  in  normal  conditions  it 
produces  no  morbid  symptoms,  yet  pyogenic  cocci  which  abound  on  the 
skin  do  not  affect  the  constitution  until  the  way  is  opened  for  their 
entrance  by  some  skin  lesion  or  by  a  surgeon's  incision.  All  the 
triumphs  of  modern  surgery  have  come  from  the  surgeon's  making  the 
skin  aseptic  before  he  cuts  into  it,  or,  as  it  is  technically  stated,  by 
sterilizing  the  skin.  In  the  intestines  such  sterlhzation  is  impracticable, 
and  only  very  recently  have  we  discovered  how  the  Bacillus  coli  can 
penetrate  mucous  membranes  and  gain  entrance  into  the  circulation, 
thus  producing  a  great  variety  of  infections  whose  nature  and  origin 
were,  till  lately,  fully  obscure.  Thus,  the  kidneys  may  be  invaded  by 
this  bacillus,  with  the  result  of  producing  a  great  number  of  small, 
scattered  abscesses  through  this  substance,  from  which  the  Bacillus 
coli  can  be  isolated  in  pure  culture,  as  we  shall  note  further  on. 

One  peculiarity  is  by  no  means  uncommon  in  the  appearance  of  the 
urine,  which  is  highly  acid  and  has  no  ammoniacal  odor,  but  instead 
has  a  special  appearance,  as  if  it  held  minute  whitish  substances  in 
suspension.  On  examination  by  the  microscope  with  proper  reagents 
they  prove  to  consist  of  millions  of  the  Bacillus  coh. 

I  was  once  called  in  consultation  by  Dr.  Robert  Abbe  to  see  a 
lady  who  presented  symptoms  of  cerebral  disorder,  along  with  febrile 
temperature.  This  condition  of  the  urine  in  her  continued,  notwith- 
standing measures,  to  be  mentioned  presently,  which  had  always  been 
successful  in  ridding  the  urine  of  the  Bacillus  coU.  The  whole  prob- 
lem was  subsequently  solved  by  an  attack  of  severe  appendicitis. 

232 


INFECTIONS    BY    THE    BACILLUS    COLI  233 

When  Dr.  Abbe  operated  to  remove  the  appendix,  a  broad  ulcer  at 
the  attachment  of  the  appendix  to  the  cecum  plainly  showed  where 
the  bacillus  had  gained  entrance  into  the  circulation.  After  the  opera- 
tion the  remedies  quickly  relieved  the  patient  of  every  trace  of  her 
special  infection. 

One  of  the  results  of  acute  infection  by  this  organism  is  a  sudden 
development  of  cerebral  symptoms,  soon  passing  into  coma  and  high 
fever. 

I  was  once  called  in  consultation  by  two  physicians  to  see  a  lady  over 
fifty  who  was  comatose  with  a  temperature  of  105°  F.  They  stated 
that  her  urine  was  highly  albuminous  and  that  for  some  years  she  had 
suffered  from  chronic  colitis.  On  examining  the  patient  I  felt  sure 
it  was  a  condition  of  acute  nephritis  caused  from  infection  by  the 
Bacillus  coli,  and  recommended  my  usual  treatment  for  such  cases. 
This  was  followed  by  rapid  and  complete  recovery. 

If  it  can  be  shown,  however,  that  the  patient  has  previously  suffered 
from  chronic  ulcerative  conditions  of  the  intestine,  the  prognosis  is 
good.  But  in  one  case,  that  of  a  physician  who  had  already  consulted  me 
for  ulcerative  colitis,  I  was  called  to  see  him  by  his  physicians,  who  told 
me  that  for  seven  weeks  he  had  been  so  continuously  delirious  that  his 
attendants  had  to  watch  him  day  and  night.  Meantime  his  urine 
had  been  daily  examined  at  a  well-equipped  laboratory,  and  found 
constantly  to  contain  much  albumin,  with  blood  and  tube-casts.  Their 
report,  therefore,  was  uniform  with  the  diagnosis  of  severe  parenchy- 
matous nephritis.  On  my  examining  him,  I  said  this  was  a  laboratory 
and  not  a  clinical  diagnosis,  because  his  pulse  was  soft  and  he  had  no 
sign  of  dropsy.  Meantime  I  gave  a  favorable  prognosis,  and  pre- 
scribed my  usual  remedies  for  infection  by  the  Bacillus  coli.  The 
report  from  the  laboratory  on  the  second  day  after  the  treatment 
began  was,  "Astonishing  improvement;  no  albumin,  no  blood,  and  no 
casts."  Six  weeks  afterward  this  physician  called  upon  me  wholly 
free  from  any  symptoms. 

One  hardly  knows  what  the  colon  bacillus  will  not  do  when  once 
it  starts  on  its  travels  in  the  circulation.  Dr.  Robert  T.  Morris,  the 
well-known  surgeon  of  New  York,  reports  in  the  "New  York  Medical 
Journal,"  January  i,  1910,  the  case  of  a  patient,  an  elderly  clergyman, 
referred  to  him  by  Dr.  S.  Kirchendal,  of  Ithaca,  N.  Y.,  as  a  sufferer 
from  choroiditis,  which  threatened  to  end  in  total  blindness.  In  his 
letter  to  Dr.  Morris,  Dr.  Kirchendal  says  that  Dr.  Stockton,  of  Buffalo, 
has  long  maintained  that  the  colon  bacillus  was  the  cause  of  most 
cases  of  choroiditis.     Dr.  Morris  found  that  his  patient  had  been  suffer- 


234  CLINICAL  MEDICINE 

ing  for  years  from  intestinal  troubles  accompanied  by  symptoms  of 
chronic  appendicitis,  and  on  Dr.  Morris'  removing  the  appendix  the 
patient  recovered,  not  only  from  his  intestinal  troubles,  but  also  from 
his  choroiditis. 

Recent  medical  Hterature  abounds  with  references  to  serious  effects 
of  invasion  of  the  Bacillus  coh  in  producing  extensive  organic  changes 
between  different  pelvic  viscera.  In  the  London  "Lancet"  of  October 
30,  1909,  Dr.  F.  Charlton  Briscoe,  Physician  to  Kings  College  Hospital, 
London,  relates  several  instances  of  a  matting  together  of  the  pelvic 
viscera  by  an  exudate,  showing  caseous  changes  which  led  to  mistaken 
diagnosis  of  their  tuberculous  nature,  but  which  proved,  on  microscopic 
examination,  to  be  caused  by  the  Bacillus  coh.  In  each  case  colon 
bacilli  were  found  abundantly  in  the  urine.  Among  other  cases  there 
was  that  of  a  young  girl,  in  whom  on  operation  a  large  mass  of  caseous 
material  was  found  attached  to  the  small  intestine,  great  omentum, 
left  ovary,  and  tube.  This  was  thought  to  be  surely  tuberculous,  but 
on  examination  no  tubercle  bacilli  were  found,  but  instead  a  structure- 
less material  from  which  pure  cultures  of  colon  bacilli  were  obtained. 
He  also  refers  to  an  interesting  group  of  cases  which  have  attacks  of 
intermittent  fever,  but  which  prove  so  commonly  to  be  due  to  colon 
infection  that  he  advises  the  urine  to  be  examined  for  the  colon  bacilli 
in  all  cases  of  febrile  attacks  of  obscure  origin. 

Likewise,  Dr.  H.  Batty  Shaw,  Physician  to  the  University  College 
Hospital,  London,  gives  the  particulars  of  7  cases  of  his  own  which 
may  have  been  supposed  to  be  sufferers  from  malaria,  tuberculosis, 
mucous  colitis,  cystitis,  acute  suppressions,  or  pernicious  anemia,  and 
yet  which,  on  examination  of  the  urine,  proved  to  be  cases  of  infection 
by  the  Bacillus  coH. 

As  might  be  expected,  invasion  of  the  kidney  by  the  Bacillus  coli 
is  not  an  uncommon,  and  sometimes  a  fatal,  compHcation  of  typhoid 
fever  in  its  later  stages,  when  the  intestine  is  extensively  ulcerated. 
Its  supervention  should  be  suspected  when  markedly  increased  albu- 
minuria is  detected  along  with  excess  of  delirium.  One  symptom  is  an 
almost  certain  sign,  namely,  the  occurrence  of  severe  rigors  late  in  the 
typhoid  fever.  During  these  attacks  the  patient  seems  on  the  verge 
of  dissolution,  and  yet  they  are  not  necessarily  fatal,  particularly  in 
young  subjects.  Free  dosing  with  spirit  of  chloroform  cuts  the  rigors 
short.  In  older  patients  the  prognosis  is  worse  and  in  one  case  of 
my  own,  that  of  a  lady  about  fifty  who  soon  died,  the  bacteriologist 
reported  that  he  had  never  seen  such  a  vast  collection  of  the  colon 
bacilH  as  there  was  in  her  urine. 


INFECTIONS    BY    THE    BACILLUS    COLI  235 

As  regards  chronic  infection  by  the  Bacillus  cob",  we  would  refer 
to  an  iniportant  paper  in  the  "Journal  of  Medical  Research,"  Novem- 
ber, 1902,  by  Dr.  A.  Charlton,  from  the  pathologic  laboratories  of 
the  McGill  University,  with  the  title  "The  Anemia  Produced  by  Re- 
peated Injections  of  Cultures  of  a  Colon  Bacillus  of  a  Low  Virulence." 
Rabbits  were  used  for  experiments  with  the  colon  bacillus  derived  from 
their  own  intestines;  the  cultures  therefrom  were  injected  into  a 
vein  of  the  ear.  The  doses  were  always  small  during  a  period  of 
experimentation  extending  over  many  weeks.  The  results  were  a  very 
remarkable  state  of  advanced  anemia,  in  some  respects  strikingly  Hke 
the  condition  found  in  pernicious  anemia,  namely,  great  diminution 
in  the  number  of  red  cells,  marked  poikilocytosis,  and  the  appearance  of 
crescents,  macrocytes,  microcytes,  and,  lastly,  nucleated  red  cells.  On 
suspending  the  injections  for  some  weeks,  even  when  the  fall  in  the 
red  cells  was  from  5,500,000  to  only  1,500,000,  spontaneous  recovery 
took  place.  Then  when  the  injection  of  the  bacilU  was  resumed,  the 
injurious  results  were  even  more  marked  than  on  the  first  trial.  But 
in  addition  to  the  effects  on  the  blood,  very  striking  and  progressive 
changes  were  produced  in  the  spinal  cord,  consisting  of  diffuse  degenera- 
tion in  the  columns  of  GoU,  closely  resembling  the  conditions  occurring 
in  the  spinal  cord  in  pernicious  anemia. 

One  of  the  commonest  causes  of  infection  by  the  Bacillus  coli  is 
chronic  constipation,  which  may  be  obstinate  and  prolonged  for  many 
years,  especially  among  women.  I  have  found  this  bacillus  abounding 
in  the  urine,  though  there  was  no  apparent  ulceration  present  in  the 
mucous  membrane  of  the  intestines,  showing  that,  like  the  tubercle 
bacillus,  the  Bacillus  coU  can  make  its  way  into  the  circulation  without 
any  noticeable  lesion  in  the  intestinal  wall. 

Treatment. — The  treatment  of  infections  by  the  Bacillus  coli  of 
the  urinary  tract  from  the  kidneys  down  is  fortunately  very  plain. 
We  possess  in  urotropin  a  prompt  and  effective  poison  for  this 
bacillus,  which,  moreover,  is  itself  secreted  from  the  blood  by  the  kid- 
neys. I  have  found,  however,  that  urotropin  itself  often  irritates  the 
urinary  passages,  in  some  cases  even  producing  strangury,  but  this 
complication  can  be  almost  certainly  prevented  by  combining  the  uro- 
tropin with  the  same  amount  of  benzoate  of  soda,  as  this  makes  a 
combination  which  is  very  soluble  in  water  and  is  also  tasteless. 
My  usual  dose  is  10  gr.  of  urotropin  and  10  gr.  of  sodium  benzoate,  to 
be  given  in  water  or  in  Vichy,  an  hour  after  each  meal  and  at  bedtime. 
In  the  case  of  children  half  the  dose  may  be  sufficient. 

Many  cases  of  enuresis  in  children  have  been  reported   as  the 


236  CLINICAL  MEDICINE 

result  of  infection  by  the  Bacillus  coli,  and  these  have  been  equally- 
benefited  by  this  combination. 

Some  writers  have  advocated  the  use  of  vaccines  made  from  cultures 
of  the  bacilli  supplied  by  the  patients  themselves,  but  I  have  never  had 
occasion  to  resort  to  them. 

I  have  little  doubt  that  many  cases  of  chronic  interstitial  nephritis 
are  caused  directly  by  the  action  of  the  Bacillus  coli.  It  is  in  these 
patients  also  that  sudden  attacks  of  exacerbation  of  previous  kidney 
disease  follows  upon  errors  of  diet.  I  therefore  always  feel  concerned 
when  I  hear  of  an  attack  of  cholera  morbus  in  an  elderly  person,  and 
direct  that  the  condition  of  the  kidney  shall  be  immediately  investi- 
gated, for  not  infrequently  total  suppression  follows  such  attacks. 
In  such  cases  we  cannot  be  too  prompt  in  recourse  to  rectal  irrigation 
with  Kemp's  rectal  irrigator,  using  from  2  to  4  gallons  at  a  time,  every 
four  hours,  besides  dry  cupping  over  the  kidneys  both  before  and 
behind,  as  well  as  the  administration  of  urotropin  and  benzoate  of 
soda  every  three  or  four  hours,  given  per  rectum,  in  cases  of  vomit- 
ing or  coma,  these  drugs  being  very  soluble  and  suspended  in  enema 
of  4  to  6  oz.  of  normal  saline. 


PART  III 
DISEASES   OF  SPECIAL  TISSUES   OR   ORGANS 


CHAPTER    I 


DISEASES  OF  THE  BLOOD 
CHLOROSIS 

The  first  subject  to  note  about  this  disorder  is  that  it  usually  occurs 
in  young  women  not  long  after  the  establishment  of  the  meastrual 
functions,  and  then  is  prone  to  relapse  during  the  subsequent  years, 
from  fifteen  to  thirty.  This  fact  of  itself  shows  that  it  is  intimately 
associated  with  the  constitutional  conditions  accompanying  menstrua- 
tion, and  its  origin,  therefore,  must  be  sought  for  in  those  conditions. 
In  a  typical  case  of  chlorosis  the  condition  of  the  blood-corpuscles  is 
characteristic  in  showing  a  marked  deficiency  of  hemoglobin,  without 
any  other  special  changes.  We  speak  of  this  because  while  in  many 
advanced  cases  of  this  disease  there  may  be  an  actual  diminution  in 
the  proportion  of  the  red  corpuscles,  yet  the  rule  is  that  the  corpuscles 
are  found  in  about  their  normal  proportions  in  the  blood,  while  the 
other  constituents  are  not  only  unaffected,  but  may  be  relatively  in- 
creased, so  that  the  volume  of  the  blood  may  be  more  than  in  health, 
constituting  what  is  called  chlorotic  plethora.  Chlorotic  girls,  there- 
fore, do  not  show  any  trace  of  emaciation,  as  they  do  in  other  anemias, 
but  are  plump,  and  with  the  pulse  quite  full,  if  not  even  incompres- 
sible. The  chief  symptoms  which  they  complain  of  are  breathless- 
ness,  owing  to  the  deficient  oxygen-carrying  property  of  their  cor- 
puscles, along  with  palpitation  of  the  heart,  and  a  more  or  less  pro- 
nounced muscular  debihty.  Their  complexion  also  often  has  a  green- 
ish-yellow tinge,  which  has  given  to  it  the  name  chlorosis.  This  is  in 
no  sense  a  form  of  jaundice,  for  the  sclerotics  are  very  clear. 

As  a  cHaical  fact,  there  is  a  close  relation  of  the  female  generative 
organs  with  the  innervation  of  the  organs  of  digestion.  Thus,  the  begin- 
niag  of  pregnancy  is  often  accompanied  by  persistent  nausea  or  vomit- 
ing, but  in  no  morbid  condition  is  this  fact  more  often  illustrated  than  ^ 

237 


238  CLINICAL  MEDICINE 

in  chlorosis,  which  may  be  characterized  by  the  supervention  of  the 
same  strange  perversions  to  eat  all  sorts  of  indigestible  substances, 
including  slate  pencils.  I  pubhshed  a  remarkable  case  of  a  girl  who 
was  caught  in  a  cold  thunder  shower  while  she  was  menstruating. 
This  was  followed  by  loud  borborygmi,  or  rumbling  of  the  bowels, 
which  greatly  annoyed  her  at  school,  accompanied  by  complete  con- 
stipation, resisting  the  administration  of  the  most  active  cathartics. 
Finally,  when  the  bowels  did  move,  the  passages  were  totally  devoid 
of  any  color,  so  that  they  resembled  Hme  plaster.  Vomiting  then 
occurred,  which  in  time  became  stercoraceous,  and  these,  with 
other  external  derangements  of  the  secretions,  continued  till  h^r  death 
five  months  afterward.  Postmortem  examination  showed  no  stricture 
or  other  obstruction  in  the  bowel.  In  her  case  the  first  disturbance 
was  an  apparent  paralysis  of  the  peristaltic  movement  of  the  bowels, 
and  obstinate  constipation  is  such  a  common,  but  not  invariable, 
,  accompaniment  of  chlorosis  that  Sir  Andrew  Clark  ascribed  the  whole 
disease  to  toxic  absorption  of  fecal  products  in  the  large  intestine. 

One  of  the  accompaniments  of  chlorosis  is  a  curious  teadency  to 
the  formation  of  thrombi  in  the  veins.  These  thrombi,  however,  differ 
altogether  from  the  infected  and  dangerous  thrombi  that  occur  in 
septic  conditions  of  the  blood,  because  chlorotic  thrombi  are  always 
found  to  be  sterile,  and  generally  subside  without  producing  any  se- 
rious results,  even  on  the  walls  of  the  veins  where  they  form.  In  one 
hospital  patient  of  mine  I  found  28  such  thrombi  in  different  parts 
of  the  body,  but,  as  a  rule,  the  prognosis  of  the  recovery  in  their  case 
is  good,  and  they  are  best  treated  by  painting  the  course  of  the  affected 
vein  with  tincture  of  iodin.  It  is  far  otherwise,  however,  if  the 
thrombi  are  formed  in  the  cerebral  sinuses  of  chlorotics,  for  these  may 
cause  unexpected  death. 

Treatment. — Many  cases  of  the  disease  begin  with  a  chill  of  the 
feet,  as  we  have  explained  in  our  chapter  on  Catching  Cold.  Dry,  not 
moist,  heat  applied  to  the  feet  should  then  be  assiduously  employed. 
Many  chlorotic  girls,  for  long  periods  before  the  disorder  becomes 
established,  will  be  found  to  have  suffered  from  cold  feet,  remaining 
so  for  a  long  time  after  retiring.  These  patients  should,  therefore, 
have  their  feet  warmed  before  retiring,  and  should  be  cautioned 
against  remaining  in  their  stocking  feet  for  any  length  of  time  before 
getting  into  bed.  A  heated  soapstone  or  bottles  of  hot  water  should 
be  put  in  the  bed,  especially  during  the  winter  weather.  The  bowels 
should  be  kept  open  by  aloetic  laxatives,  of  which  the  small  laxative 
pill  of  aloes  and  strychnin  is  a  good  preparation. 


CHLOROSIS  239 

Like  other  processes  of  metaboKsm,  the  assimilation  of  iron  in 
chlorosis  is  wholly  unexplained.  The  doses  of  iron  which  are  adminis- 
tered are  many  times  as  large  as  the  physiologic  dose  of  iron  which  we 
daily  take  in  our  food.  This  great  excess  of  iron  colors  the  feces  black 
as  it  is  got  rid  of  by  the  intestine.  Nevertheless  in  chlorosis  we  must 
administer  relatively  immense  doses  of  iron  to  combat  the  disease. 
But  none  of  the  fancy  organic  preparations  of  iron  will  compare  with 
the  old  sulphate  for  efficiency  in  chlorosis.  We  may  begin  with  3  gr. 
three  times  a  day  after  meals,  but  soon  increase,  until  the  dose  is  5 
gr.,  and  continue  this  treatment  for  four  weeks,  after  which  the  dose 
may  be  decreased  to  3  gr.,  and  kept  up  for  at  least  three  months,  so  as 
to  forestall  relapses.  It  should  be  remembered  that  relapses  in  chloro- 
sis are  frequent,  but  generally  from  the  patients  leaving  off  the  remedy 
before  the  cure  is  attained.  Along  with  the  administration  of  iron 
it  is  well  to  administer  i  gr.  of  quinin  with  i  gr.  of  powdered  nux 
vomica,  in  pill  form,  to  be  taken  before  meals,  with  a  full  dose  of  dilute 
hydrochloric  acid  of  from  10  to  15  drops. 

The  undoubted  success  of  giving  iron  in  chlorotic  anemia  has 
injuriously  led  to  the  administration  of  iron  for  every  form  of  anemia. 
But  iron  is  positively  mischievous  in  all  anemias  associated  with  fever, 
and  hence  aggravates  the  anemia  of  tuberculosis.  Cod-Hver  oil,  as 
was  long  ago  pointed  out  by  Simon,  especially  in  the  anemias  of  chil- 
dren, is  a  much  more  effective  agent  for  enriching  the  blood  with  red 
corpuscles  than  iron,  and  iron  is  not  only  useless,  but  actually  harmful, 
in  pernicious  anemia. 

It  is  the  disproportionate  growth  of  the  brain  in  the  human  species 
in  early  life  that  causes  a  large  proportion  of  deaths  in  childhood. 
The  blood  in  children,  especially  between  the  second  and  seventh  years, 
is  poorer  in  its  proportion  of  red  corpuscles  than  it  wiU  be  again  during 
hfe.  This  is  due  to  the  great  drain  upon  the  blood  produced  by  the 
rapid  growth  of  the  brain,  because  no  organ  of  the  body,  except  the 
pregnant  uterus,  grows  so  rapidly  as  does  the  brain  during  that  period 
of  life,  so  that  its  full  weight  is  attained  by  the  end  of  the  seventh  year. 
Not  only  does  the  brain  then  increase  so  disproportionately  in  size  to 
the  rest  of  the  body,  but  it  also  does  more  and  better  work  than  it 
will  ever  do  again  during  life .  For  not  only  does  it  acquire  language  then, 
but  also  its  greatest  store  of  ideas  and  memories.  In  starvation  the 
only  tissue  of  the  body  that  does  not  lose  bulk  is  the  nervous  tissue. 
Being  the  royal  tissue,  it  will  have  its  supply  of  blood,  however  seri- 
ously the  other  tissues  may  be  starved.  Hence  it  is  due  to  this  drain 
upon  the  blood  that  those  serious  disorders  of  nutrition  occur  which 


240  CLINICAL  MEDICINE 

are  characteristic  of  childhood,  such  as  mucous  catarrhs,  diseases  of 
the  skin,  ulceration  of  the  cornea,  and  of  other  cartilaginous  tissues 
connected  with  joints.  For  them  it  is  cod-liver  oil  which  should  be 
administered  and  not  iron.  Moreover,  children  generally  show  a 
remarkable  taste  for  cod-Hver  oil,  showing  that  there  is  a  positive 
liking  for  it  which  surprises  their  parents,  just  as  parents  are  surprised 
on  finding  that  the  boy  will  wear  about  the  same  sized  hat  as  his  father. 

ANEMIAS,  PRIMARY  AND  SECONDARY 

The  commonest  affections  of  the  blood  are  the  anemias,  which  may 
be  divided  into  the  primary  anemias,  and  the  class  of  secondary  ane- 
mias. The  secondary  anemias  include  all  those  cases  of  impoverish- 
ment of  the  blood  due  to  febrile  infections,  such  as  malaria,  rheu- 
matism, tuberculosis,  and  the  acute  fevers,  also  the  anemias  of  toxic 
origin,  such  as  chronic  lead-  and  arsenic-poisoning.  The  primary 
anemias  are  those  due  to  perversions  in  the  blood-rriaking  organs  or 
tissues,  as  in  chlorosis  or  in  pernicious  anemia,  though  it  is  very 
probable  that  toxemias  of  various  kinds  have  a  share  in  the  causation 
of  the  disorder. 

The  red  corpuscles  of  the  blood  arise  from  different  tissues  in  the 
course  of  life,  those  in  the  vascular  area  surrounding  the  embryo  in  its 
early  stage  being  different  from  those  in  the  uterine  or  postnatal  life, 
though  they  all  have  in  common  that  remarkable  substance  called 
hemoglobin.  A  molecule  of  hemoglobin  stands  alone  among  organic 
compounds,  owing  to  its  huge  size,  for  it  contains  no  less  than  2304 
atoms,  composed  of  1130  atoms  of  hydrogen,  712  atoms  of  carbon, 
245  atoms  of  oxygen,  214  of  nitrogen,  2  of  sulphur,  and  i  of  iron,  and 
if  it  were  not  for  that  one  atom  of  iron  it  would  not  have  its  character- 
istic red  color,  nor  would  it  be  the  oxygen  carrier  of  the  blood.  Dur- 
ing postnatal  and  adult  life  the  chief  source  of  the  red  corpuscles  is 
from  the  red  bone-marrow,  especially  in  the  ribs.  In  this  marrow  are 
found  relatively  large  corpuscles  which  are  at  first  pale,  but  soon  become 
colored.  Some  of  these  corpuscles  are  nucleated,  others,  of  smaller 
size,  are  called  normoblasts,  w^hile  others  are  free,  non-nucleated,  bi- 
concave disks,  which  constitute  the  chief  mass  of  the  red  corpuscles 
of  the  blood.  A  peculiarity  of  the  red  corpuscles  is  that  they  are 
short  Hved,  and  appear  to  be  destroyed  in  the  spleen  and  in  the  liver. 
There  is  no  doubt  that  rapid  destruction  of  the  red  corpuscles  may  occur 
from  the  action  of  the  nervous  system  alone.  Two  competent  ob- 
servers of  my  acquaintance  counted  the  proportion  of  the  red  corpuscles, 
in  an  evening,  when  they  proposed  to  sit  up  all  night  with  a  patient, 


PERNICIOUS   ANEMIA  24I 

who  was  passing  through  a  serious  crisis  in  his  illness.  Then  on  count- 
ing the  corpuscles  again,  in  the  morning,  they  found  the  average  loss 
to  have  been  more  than  15  per  cent.  This  explains,  also,  the  frequent 
occurrence  of  abundant,  pale,  and  neutral  urine  after  nervous  strain. 
This  urine  not  only  will  contain  an  excess  of  phosphates,  but,  upon 
boihng  with  a  strong  mineral  acid,  will  turn  a  blood-red  color,  due  to 
the  hematin  dissolved  and  decolorized  in  the  urine,  but  which  color 
the  strong  acid  restores,  and  it  can  be  extracted  by  ether,  this  hematin 
being  an  active  diuretic.  I  have  thus  suspected  that  some  cases  of 
chronic  kidney  trouble,  occurring  in  persons  subject  to  much  mental 
strain,  may  originate  from  prolonged  stimulation  by  the  nervous 
system. 

The  secondary  anemias  need  not  here  long  detain  us,  as  they  are 
due  very  commonly  to  infections  such  as  malaria,  etc.,  above  men- 
tioned, and  which,  therefore,  will  be  spoken  of  as  we  treat  their  various 

causes. 

PERNICIOUS  ANEMIA 

Pernicious  anemia  is  due  to  a  specific  change  in  the  blood,  first 
described  by  the  great  Enghsh  physician  Addison.  It  is  character- 
ized by  changes  in  the  red  corpuscles  which  are  truly  specific,  not  only 
being  reduced  in  number  beyond  what  they  are  in  any  other  anemia — 
in  Quincke's  case  down  to  143,000  per  c.mm. — but  the  corpuscles  are 
characteristically  altered  in  their  shape  more  than  what  occurs  in  any 
other  known  disease.  This  condition,  which  also  occurs  in  other 
anemias,  but  never  to  such  an  extent,  has  been  called  poikilocytosis , 
the  corpuscles  departing  widely  from  their  natural  form.  In  pernicious 
anemia  they  are  characterized  by  their  abnormally  increased  size,  so 
that  they  are  called  megaloblasts,  though  some  of  them  may  be 
smaller,  so  as  to  be  called  normoblasts,  or  even  microcytes.  One 
peculiarity  of  pernicious  anemia,  which  so  differs  from  the  corpuscles 
of  chlorosis,  is  that  the  percentage  of  hemoglobin  is  usually  high,  so 
that  some  of  the  microcytes  present  a  brilhant  red  appearance. 

Clinical  Course. — This  disease  occurs  mostly  in  persons  beyond 
middle  hfe,  and  more  in  men  than  in  women.  It  is,  however,  char- 
acterized by  remarkable  remissions  which  last  for  months,  with  an 
increased  formation  of  blood-corpuscles,  so  as  to  give  deceptive  hopes 
of  recovery.  During  these  remissions  the  blood  count  materially  rises, 
but  the  serious  ultimate  prognosis  still  obtains  from  the  presence  in 
the  blood  of  nucleated  red  corpuscles  as  well  as  the  megaloblasts. 
The  white  corpuscles  are  generally  decreased  in  number,  especially  in 
the  proportion  of  polynuclears.     The  onset  of  the  disease  is  always  slow 

16 


242  CLINICAL  MEDICINE 

and  insidious,  the  patients  not  feeling  unwell  or  debilitated  until  the 
languor  caused  by  their  serious  anemia  leads  them  to  consult  a  phys- 
ician, when  an  examination  of  the  blood  first  demonstrates  the  serious- 
ness of  their  condition. 

Unlike  most  other  anemias,  there  is  no  loss  of  flesh,  and  scarcely 
any  other  palpable  sign  of  the  disease,  except  occasionally  edema  of  the 
feet.  In  pernicious  anemia  the  muscular  tissues  have  a  characteristic 
red  color,  and  the  face  also  has  a  reddish  tinge.  The  greatest  change 
is  found  in  the  bone-marrow,  which  is  greatly  wasted,  and  contains  an 
excess  of  large  nucleated  blood-corpuscles,  as  if  the  marrow  were 
making  an  extra  effort  to  replenish  the  blood.  Coincident  with  these 
changes,  and  by  some  stated  to  precede  the  other  alterations,  are 
extensive  degenerations  in  the  spinal  cord,  particularly  of  the  pos- 
terior and  lateral  columns,  so  that  some  of  these  cases  have  been  mis- 
taken for  tabes.  The  skin  is  generally  of  a  lemon  color,  but  this  can- 
not be  confounded  with  jaundice,  because  the  sclerotics  are  of  a  pearly 
white.  One  characteristic  change  is  found  in  the  liver,  which  contains 
a  great  excess  of  iron,  and  which  may  have  a  bearing  upon  the  obscure 
etiology  of  the  disease,  as  indicating  some  active  hemolytic  poison 
in  the  intestinal  tract.  The  urine  also,  but  not  always,  is  of  a  dark 
red  color,  said  to  be  due  to  an  excess  of  urobihn. 

Etiology. — The  etiology  of  this  complaint  is  very  obscure.  Hunter 
claims  that  its  most  frequent  cause  is  an  atrophy  of  the  gastric  secre- 
tory tubules,  brought  about  by  the  constant  swallowing  of  highly  in- 
fected pus  from  the  roots  of  decayed  teeth.  He  claims  that  a  further 
indication  of  this  condition  is  furnished  by  an  extensive  inflammation 
of  the  tongue,  or  chronic  glossitis.  While  there  may  be  no  doubt  that 
this  contention  is  true  in  numerous  cases  of  a  severe  anemia  with  ac- 
companying blood  changes,  yet  some  changes  of  pernicious  anemia 
show  no  evidence  of  the  infections,  either  from  the  mouth  or  atrophic 
changes  in  the  stomach,  and  we  are  compelled  to  ascribe  the  disease  to 
the  genesis  of  an  unknown  hemolytic  poison,  most  probably  generated 
in  the  intestinal  tract.  This,  however,  does  not  explain  the  singular 
remissions,  which  in  no  sense  are  intermissions  like  those  which  may 
occur  in  malarial  affections.  Pernicious  anemia  is  also  a  febrile  disease, 
the  thermometer  often  ranging  from  ioi°  to  102.5°  F.,  without  any 
constant  connection  with  the  occurrence  of  remissions.  These  re- 
missions, in  fact,  constitute  one  of  the  most  obscure  features  of  the 
complaint.  As  in  other  grave  anemias,  the  heart  walls  show  patches 
of  fatty  degeneration,  and  death  occurs  from  pure  muscular  debility, 
and  not  from  intercurrent  diseases. 


LEUKEMIA  243 

Treatment. — The  only  remedy  which  has  any  reputation  is  ar- 
senic; iron,  from  what  we  have  already  said,  being  contra-indicated  in 
the  treatment,  as  in  all  other  febrile  complaints.  The  administration 
of  arsenic  may  begin  with  5  drops  of  Fowler's  solution,  three  times  a 
day,  gradually  increased  to  the  point  of  tolerance  by  the  stomach. 
Some  recommend  no  less  than  20  drops  at  a  dose.  In  one  of  my  cases 
remarkable  improvement  occurred  for  a  time  from  the  administration 
of  bone-marrow,  but  ultimately  this  failed  and  the  patient  died  with 
all  the  symptoms  of  extreme  impoverishment  of  the  blood. 

LEUKEMIA 

This  fatal  disorder  of  the  blood  is  not  restricted  to  the  human 
species,  but  has  been  reported  as  occurring  in  horses,  dogs,  oxen,  cats, 
swine,  and  mice.  This  fact  is  without  a  parallel  in  any  other  disease, 
and  shows  that  the  processes  in  blood  making  are  essentially  the  same 
throughout  all  the  vertebrates.  It  also  indicates  how  deep  seated  the 
disorder  must  be,  for  the  blood  is  the  most  vital  element  in  animal  hfe, 
and  it  is  now  proposed  that  the  specific  chemical  reaction  of  a  single 
drop  of  blood  should  be  made  the  basis  of  zoologic  classification. 
On  this  account  the  etiology  and  pathology  of  leukemia  must  be  un- 
known, and  what  remains  for  us  is  rather  to  study  its  different  cHnical 
forms.  Of  those  chnical  forms  the  most  commonly  recognized  is  that 
in  which  the  spleen  is  enlarged  and  inflamed,  so  that  it  frequently  forms 
adhesions  to  surrounding  parts.  But  this  fact  throws  no  hght  on  the 
nature  of  this  disease,  for  the  spleen  is  an  organ  which  is  not  necessary 
to  life,  and  has  been  both  experimentally  removed  in  animals  and  sur- 
gically excised  in  man  without  serious  results,  which  would  be  impos- 
sible in  the  case  of  organs  so  much  smaller  than  the  spleen,  as  the  adre- 
nals. No  splenic  disease,  therefore,  can  be  the  cause  of  leukemia,  but 
enlargement  of  the  spleen  so  frequently  enters  into  the  picture  of  this 
complaint  as  to  give  the  name  "splenomeduUary"  to  one  variety. 
The  real  seat  of  the  disease  is  in  the  bone-marrow,  the  chief  source  of 
the  corpuscular  elements  of  the  blood. 

Another  clinical  form  is  that  in  which  the  lymphatic  glands  and 
the  whole  lymphoid  tissue  of  the  body  is  imphcated.  As  a  rule,  this 
form  is  more  rapidly  fatal  than  the  previous  one,  but  is  also  so  associ- 
ated with  the  same  changes  in  the  bone-marrow  as  the  previous  form 
that  it  is  a  question  whether  there  is  any  essential  difference  in  the 
conditions  underl3dng  these  two  varieties  of  leukemia. 

Symptoms. — As  a  rule,  the  onset  of  this  disease  is  so  insidious  that 
its  actual  beginning  may  not  come  under  the  notice  of  the  physician. 


244  CLINICAL  MEDICINE 

Not  infrequently  the  patients  feel  quite  well,  and  continue  in  their 
avocations  wholly  unaware  of  the  disastrous  changes  which  have  al- 
ready happened  to  them  in  their  blood.  Quincke's  extraordinary  case 
is  referred  to  by  all  authors,  where,  instead  of  the  red  cells  numbering 
5,000,000,  they  amounted  to  only  143,000  per  c.mm.,  and  yet  the  patient 
did  not  know  that  he  was  seriously  ill.  The  diagnosis  of  leukemia, 
therefore,  cannot  be  made  from  its  symptoms,  but  only  by  micro- 
scopic examination  of  the  blood. 

Under  the  microscope  the  first  fact  of  importance  is  a  great  rela- 
tive increase  of  the  white  corpuscles.  Instead  of  i  white  corpuscle 
to  800  red  corpuscles,  the  proportion  may  be  i  to  200,  i  to  50,  or  even 
I  to  I.  Cases  have  been  reported  where  the  white  corpuscles  have 
exceeded  the  number  of  red,  but,  besides  this,  the  red  may  be  actually 
diminished  much  below  1,000,000  to  the  c.mm.  In  addition  to 
these  changes,  new  forms  of  corpuscles  not  found  in  normal  blood  make 
their  appearance.  Sometimes  the  red  corpuscles  are  nucleated;  at 
other  times  very  large  forms  are  found,  called  megaloblasts.  White 
corpuscles,  called  myelocytes,  unlike  those  found  in  normal  blood,  ap- 
pear in  great  numbers.  These  myelocytes  show  scarcely  any  of  the 
ameboid  movements,  and  are  not  colored  by  basophihc  stains.  Poi- 
kilocytosis  also  appears,  but  is  not  so  common  as  in  pernicious  anemia. 

The  symptoms  which  ordinarily  cause  a  patient  to  consult  a  phys- 
ician are  those  of  general  debility,  as  might  be  expected  from  the 
progressive  anemia,  but  very  commonly  there  is  a  tendency  to  various 
hemorrhages,  particularly  epistaxis.  A  similar  tendency  occurs  in 
the  gums,  but  the  most  dangerous  form  is  from  hemorrhage  in  the 
stomach,  sudden  fatal  hematemesis  having  been  reported  as  a  first  sign 
of  the  complaint,  and  found  postmortem  to  be  without  any  connection 
with  gastric  ulcer.  In  other  cases  ecchymoses  and  true  purpuric  spots 
appear  under  the  skin. 

The  ordinary  duration  of  this  disease  is  from  two  to  three  years, 
but  occasionally  acute  forms  appear,  one  of  which  I  pubhshed  in  the 
"New  York  Medical  Record,"  March  5,  1898,  of  a  married  woman,  aged 
twenty-one,  whose  first  symptom  of  illness  came  on  three  weeks  before 
she  was  admitted  on  June  8th,  and  who  died  on  June  19th.  She  had 
a  temperature  of  105.6°  F.  on  admission.  The  spleen  could  scarcely 
be  felt,  and  there  were  no  enlarged  lymphatic  glands  palpable,  nor  any 
cutaneous  ecchymoses.  The  first  blood-count  made  the  morning 
after  admission  was  1,400,000  red  cells  per  c.mm.,  and  hemoglobin 
only  27  per  cent.  She  had  repeated  attacks  of  vomiting,  which  contin- 
ued until  her  death.     The  hver  showed  an  enormous  collection  of  large 


HEMOPHILIA  245 

mononuclear  cells,  while  the  parenchymatous  liver  cells  were  remark- 
ably fatty.  The  chief  change,  however,  was  in  the  bone-marrow,  the 
shaft  of  the  femur  containing  almost  diffluent,  light-colored,  bloodless 
marrow,  which  could  with  difficulty  be  distinguished  from  pus,  on  the 
one  hand,  and  fat  on  the  other.  Taking  this  case  as  a  whole,  there  was 
no  doubt  of  its  being  leukemia,  from  the  presence  of  special  forms  of 
cells  above  described  and  also  myelocytes,  yet  the  high  fever  along 
with  the  other  features  of  the  attack  strongly  suggested  some  infective 
process. 

Treatment. — For  the  treatment  of  this  disease  the  most  favorable 
report  is  from  the  employment  of  the  x-rays,  though  it  is  difficult  to 
explain  the  mechanism,  so  to  speak,  of  this  agent.  Dr.  R.  C.  Cabot, 
in   Osier's  "System,"  speaks  enthusiastically  on  this  subject. 

HEMOPHILIA 

This  remarkable  affection  of  apparently  causeless  bleeding  is 
strangely  Hmited  to  the  male  sex,  but  it  is  equally  strange  that  it 
occurs  only  in  boys  who  inherit  a  family  tendency  to  the  complaint 
through  their  mothers,  who  alone  appear  to  transmit  that  tendency  or, 
in  other  words,  it  comes  from  the  maternal,  but  not  the  paternal,  side. 

In  some  cases  a  deficiency  has  been  found  in  the  development  of 
the  muscular  layer  of  the  small  arteries,  while  in  other  cases  the  blood- 
vessels are  normal  in  their  structure,  no  change  in  the  blood  itself 
having  been  conclusively  found  in  the  disease.  But  as  it  occurs 
in  boys  in  early  childhood,  every  precaution  should  then  be  taken  to 
prevent  their  receiving  injuries  causing  open  wounds  of  any  kind,  for 
uncontrolled  hemorrhage  has  occurred  from  the  extraction  of  a  tooth. 

The  hemorrhage,  however,  may  occur  spontaneously,  particu- 
larly in  the  form  of  epistaxis,  but  has  been  known  to  come  from  the 
mouth,  and  in  some  cases  from  the  kidney.  Cases  are  also  reported  in 
which  hemorrhages  under  the  skin  closely  resembhng  purpura  occur, 
but  the  commonest  development  of  the  disease  is  about  the  joints, 
which  may  be  easily  confounded  with  various  forms  of  arthritis,  being 
differentiated  from  them  by  other  manifestations  of  hemophiha.  The 
true  etiology  of  the  complaint,  however,  is  still  undiscovered. 

Treatment. — Our  only  measures  are  in  the  form  of  prophylaxis. 
The  prognosis  improves  with  each  advancing  year;  the  earher  hemo- 
philia occurs  in  childhood,  the  worse  the  prospect.  We  seem,  how- 
ever, to  have  in  ergot  a  promising  agent  through  its  effect  of  con- 
tracting peripheral  blood-vessels.  Wright  has  shown  that  the  blood 
in  cases  of  hemophilia  takes  more  than  twice  the  usual  time  for  coagu- 


246  CLINICAL   MEDICINE 

lating,  which  would  seem  to  be  an  indication  to  use  the  calcium  lac- 
tate in  doses  of  10  gr.,  taken  in  milk,  three  or  four  times  a  day.  I 
doubt  if  free  doses  of  tincture  of  perchlorid  of  iron,  recommended  by 
some,  is  of  any  avail.  Locally,  in  cases  of  epistaxis  a  strong  solution 
of  adrenahn  should  be  persistently  employed,  while  Burroughs  & 
Welcome's  tablets  of  suprarenal  extract,  recommended  in  the  treat- 
ment of  Addison's  disease,  may  be  tried. 

SCURVY 

"While  the  profession  is  indebted  to  naval  surgeons  for  the  fullest 
information  about  scurvy,  as  it  used  to  prevail  on  ships,  yet  extensive 
epidemics  of  it  have  occurred  on  land,  particularly  in  besieged  cities, 
as  in  Paris  in  187 1 .  The  French  and  English  armies  also  in  the  Crimea 
suffered  severely,  owing  to  their  faulty  supphes  of  provisions.  As  late 
as  1795  the  British  fleet  under  Lord  Howe  was  endangered  by  an 
'  extensive  outbreak  among  the  crews.  Scurvy  now  is  a  well-nigh  ex- 
tinct disease  on  sea,  due  not  only  to  the  use  of  lime-juice,  introduced 
by  Sir  Gilbert  Blanc,  but  still  more,  in  my  opinion,  to  extensive  use  of 
potatoes,  conjoined  with  the  great  shortening  of  trips  by  sea  since  the 
introduction  of  steam." 

It  was  during  the  long  voyages  of  the  i8th  century  that  the  rav- 
ages of  this  disease  on  shipboard  were  so  dreadful.  It  was  not  long 
before  experience  on  a  wide  scale,  both  on  sea  and  on  land,  proved 
that  absence  of  fresh  vegetable  food  was  the  chief  cause  of  this  disease, 
and  that  all  that  we  needed  either  to  prevent  or  to  cure  it  was  the  use 
of  fresh  vegetables. 

Symptoms. — The  prodromal  symptoms  of  this  now  fortunately 
rare  disease  are  a  sense  of  general  muscular  weakness  with  shifting  pain 
in  the  limbs  and  back.  The  skin  is  dry  and  rough,  and  marked  by 
small  purple  spots,  particularly  on  the  thighs  and  legs,  sometimes 
on  the  lower  limbs  exclusively.  Besides  these  spots,  there  are  Hvid 
patches  which  resemble  bruises.  The  tongue  may  be  swollen,  and 
there  may  be  a  tendency  to  diarrhea.  The  most  distinctive  of  the 
early  signs  is  found  in  the  state  of  the  gums,  which  are  of  a  deep  red 
color,  soft  and  vascular,  and  much  swollen.  There  is  a  pecuhar  and 
characteristic  fetor  in  the  breath.  Besides  the  affection  of  the  gums, 
there  is  the  subcutaneous  indurated  swelHng  of  the  tissues,  so  that  the 
muscles  often  seem  to  be  brawny.  These  lesions  are  specific  to  scurvy, 
as  well  as  those  disorders  of  the  skin  already  described.  General  weak- 
ness of  all  muscular  tissues,  including  that  of  the  heart,  was  the  com- 
monest cause  of  death. 


hemoglobinuria  247 

Infantile  Scurvy 

Scurvy  may  occur  in  all  its  typical  features  in  infants  and  growing 
children,  as  well  as  in  adults.  One  of  the  worst  cases  which  I  have  seen 
was  in  a  child  who  had  been  fed  exclusively  with  a  preparation  called 
HorHck's  Malted  Milk.  These  cases  can  be  promptly  cured  by  gi^^ng 
pure  milk,  and,  if  necessary,  supplemented  with  Fairchild's  essence  of 
pepsin.  For  a  long  time  infantile  scurvy  was  confounded  with  rickets, 
but  the  characters  of  this  complaint  are  plainly  scorbutic,  consisting 
of  intramuscular  and  especially  subperiosteal  hemorrhages,  most 
pronounced  in  the  lower  limbs. 

PURPURA 

Purpura  is  not  a  disease,  but  a  symptom  common  to  a  number  of 
diseases.  It  consists  virtually  in  an  inability  of  the  blood  capillaries 
to  retain  the  blood  coursing  in  them,  so  that  extravasations  of  blood 
take  place  under  the  skin  in  many  parts  of  the  body,  accompanied  in 
some  cases  by  inflammatory  swellings  of  the  joints,  when  it  may  be 
difficult  to  distinguish  it  from  peKosis  rheumatica.  It  is  always  of 
toxic  origin,  and  thus  it  is  not  uncommon  as  an  accompaniment  of 
jaundice,  and  may  be  the  cause  of  a  bleeding  difficult  to  control  in 
operations  upon  patients  with  jaundice.  At  other  times  it  may  not 
be  easy  to  assign  the  cause  of  the  toxemia. 

One  of  the  most  difficult  cases  in  my  practice  was  that  of  a  lady 
who,  after  various  signs  of  purpura,  had  hematuria  so  profusely  that  it 
threatened  her  Kfe,  but  was  checked  by  a  hypodermic  administration 
of  rabbit's  serum. 

I  have  found  the  most  efficacious  remedy  to  be  the  administration 
of  15  gr.  of  calcium  lactate,  four  times  a  day.  When  it  takes  the 
form  of  hematuria  it  is  apt  to  set  up  serious  diffuse  nephritis. 

HEMOGLOBINURIA 

This  disease  consists  in  the  passage  of  bloody  looking  urine,  but 
blood-corpuscles  are  not  found  in  the  secretion,  but  instead  of  that 
the  coloring-matter  of  the  blood  is  generally  diffused  throughout  the 
urine,  and  is  not  caused  by  any  derangement  in  the  kidney  or  urinary 
passages.  The  conclusion,  therefore,  is  plain  that  it  is  due  to  an  actual 
solution  of  the  corpuscles  in  the  blood  itself,  but  the  reasons  for  this 
are  very  obscure,  for  I  have  not  found  that  these  patients  are  usually 
anemic.  The  commonest  form  in  my  experience  has  been  what  is 
called  paroxysmal  hemoglobinuria,  in  which  red  urine  is  passed  at 
different  times  during^  the  day,  oftenest  in  the  morning.     Such  patients 


248  CLINICAL  MEDICINE 

have  come  to  me  as  women  who  in  their  daily  tasks  have  been  obliged 
to  keep  their  hands  in  ice  water,  as  in  the  preparation  of  vege- 
tables or  bunches  of  lettuce  before  sending  them  to  market.  Why 
the  simple  plunging  of  the  hand  into  cold  water  should  cause  hemoglo- 
binuria is  difficult  to  explain,  but  it  is  ascribed 'by  some  writers  as  due 
to  nervous  spasm  such  as  in  Raynaud's  disease.  In  Raynaud's  disease 
spasmodic  contraction  of  the  arteries  of  the  fingers  occurs,  so  that  it 
is  sometimes  called  ''dead  fingers."  I  have  also  seen  typical  examples' 
of  dead  fingers  in  hysteria,  but  what  connection  there  can  be  between 
spasm  of  the  arteries  of  the  fingers  and  the  production  of  hemoglobi- 
nuria I  cannot  imagine. 

The  treatment  of  my  cases  has  been  by  the  use  of  warm,  instead  of 
cold-water. 

CYANOSIS 

Some  forms  of  derangements  of  the  complexion  resembling  cyano- 
sis are  caused  by  analogous  changes  in  the  blood  produced  by  drugs. 
One  such  drug  which  is  less  prescribed  than  formerly  is  sulphonal, 
and  another  important  one  in  my  experience  was  veronal.  But  we 
may  have  similar  discolorations  produced  by  disorders  of  the  intes- 
tines, and  which  occur  without  being  occasioned  by  drugs.  Such  cases 
should  be  treated  at  once  by  the  administration  of  10  gr.  of  urotropin 
with  10  gr.  of  sodium  benzoate,  four  times  a  day,  an  hour  after  meals 
and  at  bedtime. 


CHAPTER    II 
DISEASES  OF  THE  CIRCULATORY  APPARATUS 

EXAMINATION  OF  THE  BLOOD-VESSELS 

Before  examination  of  the  pulse  and  of  the  heart  itself,  the  actual 
physical  conditions  of  the  circulatory  apparatus  should  be  carefully 
noted,  including  examination  of  the  arteries,  of  the  veins,  of  the  capil- 
laries, and  of  the  interstitial  circulation  outside  of  the  capillaries. 
Important  practical  information  is  thus  often  gained  about  states  of 
function  or  of  nutrition,  both  local  and  general,  which  will  materially 
assist  in  the  interpretation  of  all  other  circulatory  symptoms.  Both 
the  beats  of  the  pulse  and  the  action  of  the  heart  are  constantly  affected 
by  conditions  existing  not  only  in  the  blood-vessels  proper,  but  in 
that  important  part  of  the  circulation  to  which  everything  else  is  sub- 
sidiary, namely,  the  rapidly  moving  fluids  which  bathe  the  cells  of  the 
tissues. 

A  perfectly  healthy  radial  artery  is  impalpable,  and  can  be  located 
only  by  its  beat.  Such  arteries  found  in  a  man  fifty  years  old  imply 
that  he  belongs  to  a  long-Hved  family;  that  he  has  no  kidney  disease, 
nor  gout,  nor  lead-poisoning,  nor  emphysema,  and  it  is  unlikely  that 
he  has  any  serious  heart  disease.  But  long  before  fifty  many  persons 
are  found  with  their  radials  as  palpable  as  the  tendons  between 
which  they  lie,  or  they  can  be  rolled  under  the  finger  like  cords.  Such 
arteries  are  diseased  from  chronic  blood-poisoning  of  some  form,  lead- 
ing to  obstruction  of  their  outflow  into  the  capillaries,  and  the  first 
thing  to  determine  is  to  what  extent  the  vessel  wall  has  consequently 
become  thickened  or  changed.  It  may  be  only  thickened  by  hyper- 
trophy of  its  muscular  coat,  secondary  to  the  work  entailed  to  over- 
come the  obstruction,  and  which  thickening  is  removable  by  cessation 
of  its  cause.  If  such  be  the  case,  the  artery  feels  smooth  and  uniform, 
and  by  placing  three  fingers  along  its  course,  on  pressing  with  the 
first  finger  above  enough  to  stop  the  blood  flow,  the  other  two  fingers 
can  hardly  feel  the  collapsed  vessel  in  its  bed.  If,  on  the  other  hand, 
the  emptied  part  of  the  vessel  still  remains  plainly  palpable,  it  then  is 
more  than  simply  thickened  or  overfull,  because  its  walls  have  be- 
come altered  into  more  or  less  inelastic  tubes.     Local  atheromatous 

249 


250  CLINICAL  MEDICINE 

and  sclerotic  changes  in  the  vessel  walls  make  it  feel  no  longer  smooth 
or  uniform,  but  often  so  uneven  as  to  resemble  a  string  of  beads.  As 
we  shall  see,  atheroma  always  imphes  pre-existing  strain,  and  is  es- 
pecially present  in  arteries  at  the  seat  of  most  strain.  Another 
evidence  of  obstruction  in  front  is  that  the  vessel  becomes  tortuous. 
A  temporal  artery  coursing  up  a  bald  head  like  a  corkscrew  is  not  a 
sign  of  good  import.  The  presumption  raised  by  such  conditions  in 
the  larger  vessels  is  that  vast  numbers  of  the  arterioles  over  the  body 
have  become  obliterated,  a  surmise  which  is  confirmed  by  inspection  of 
the  pre  ternatur ally  white  abdomen  on  which  the  finger  nail  may 
be  sharply  drawn  without  producing  more  than  the  most  transient 
red  mark  on  the  anemic  skin. 

The  skin  anemic  from  other  causes  than  this  arterial  ischemia — e.  g., 
febrile  anemia — is  easily  reddened  by  friction.  Some  form  of  malnu- 
trition, therefore,  is  present  everywhere  in  such  a  body,  and  is  to  be 
taken  account  of  whenever  a  part  is  specially  attacked  by  acute  disease. 
Thus  the  prognosis  of  a  pneumonia  or  of  a  typhoid  fever  is  not  so 
favorable  with  coexisting  general  arterial  degeneration,  while  both 
cerebral  and  spinal  affections  will  have  more  serious  import. 

One  inference  from  these  signs  of  general  arterial  disease  is  that 
the  increased  work  by  the  heart  to  carry  on  the  circulation  through 
such  altered  vessels  will  lead  to  its  hypertrophy  and  ultimately  to  its 
dilatation.  On  the  other  hand,  marked  hypertrophy  of  the  heart  and 
dilatation  may  occur  with  but  moderate  atheromatous  changes  in  the 
arteries,  and,  vice  versa,  extensive  atheromatous  changes  may  be 
found,  especially  in  the  aged,  without  cardiac  hypertrophy. 

Some  writers  (Schmaus)  have  tried  to  explain  these  facts  by  assum- 
ing that  only  extensive  atheromatous  changes  in  the  abdominal  arteries 
will  suffice  CO  produce  cardiac  hypertrophy,  but  this  statement,  still 
lacks  proof.  Atheromatous  patches  are  always  more  or  less  local  in 
their  distribution,  and  some  obstruction  more  general  than  anything 
simply  local  seems  called  for  to  explain  the  effects  upon  the  heart. 

Now,  it  has  been  demonstrated  that  the  internal  secretion  of  the 
adrenal  glands  is  essential  to  life,  owing  to  its  property  of  toning  up 
the  entire  arterial  system.  A  very  slight  excess,  therefore,  of  this 
secretion  in  the  blood  will  cause  such  universal  arterial  contraction 
that  it  will  entail  more  labor  on  the  heart  than  any  local  atheromatous 
changes,  however  extensive  (as  will  be  noted  in  the  chapters  on  Neph- 
ritis) . 

Marked  atheromatous  changes  in  the  aorta  and  larger  vessels  have 
been  caused  experimentally  in  rabbits,  dogs,  and  cats — animals  not 


EXAMINATION    OF   THE   BLOOD-VESSELS  25 1 

prone  to  such  arterial  disease — by  long-continued  administration  of 
adrenalin,  evidently  from  the  strain  produced  by  this  artificial  hyper- 
tension of  the  arterial  flow.  The  presence  of  excess  of  adrenalin  also 
explains  the  initial  tension  and  overfilUng  of  the  arteries  in  recent 
kidney  disease  better  than  the  theory  of  vasomotor  spasm,  as  this  can 
hardly  be  as  continuous  or  universal  as  the  condition  found  in  the 
systemic  circulation  in  such  cases. 

It  may  readily  be  inferred  that  persons  wdth  a  diseased  arterial 
system  are  liable  to  aneurysmal  dilatation  and  to  rupture  of  these 
vessels.  A  patient,  therefore,  who,  after  a  sudden  attack  of  hemi- 
plegia, shows  no  palpable  changes  in  his  arteries,  should  suggest  em- 
bolism or  syphilis  rather  than  cerebral  hemorrhage  as  a  cause  of  his 
symptoms. 

Arterial  changes  of  this  kind  are  incident  to  old  age  as  such,  but 
there  is  a  wide  range  of  years  between  individuals  in  this  respect.  A 
proneness  to  apoplexy  or  to  other  accidents  due  to  diseased  vessels 
is  often  a  family  trait,  and  has  suggested  the  statement  that  a  man  is 
as  old  as  his  arteries. 

Another  condition  to  be  noted  in  the  arterial  system  is  throbbing, 
by  which  is  meant  undue  visible  or  palpable  pulsation.  This  may  be 
either  local  or  general.  One  form  of  widely  distributed  pulsation  is 
owing  to  regurgitation  through  the  aortic  valves,  and  the  best  locaHty 
to  observe  it  is  at  the  bend  of  the  elbow,  when,  on  flexing  the  joint, 
the  brachial  artery  can  be  seen  to  throb  both  above  and  below  the 
joint  in  a  fashion  which  is  pathognomonic  of  this  cardiac  lesion,  and 
hence  is  confirmatory  of  the  auscultatory  signs.  In  old  people  a 
moderate  degree  of  throbbing  may  be  observed  in  ah  the  large  arteries. 
In  younger  persons  pulsation  of  the  arteries  of  the  neck  is  suggestive 
of  cardiac  valvular  disease,  but  may  be  quite  pronounced  in  anemic 
patients,  particularly  under  emotion,  without  any  valvular  lesion. 
Pulsation  in  the  subclavian  artery  may  be  a  valuable  sign  of  disease, 
with  shrinkage  of  the  apex  of  a  lung  drawing  upon  the  artery  by 
pleuritic  adhesions.  Such  a  lung  change  may  even  make  the  pulsa- 
tion of  the  arch  of  the  aorta  visible.  Pulsation  visible  on  the  surface 
of  the  chest,  away  from  the  normal  limits  of  the  pericardium,  should 
always  suggest  aneurysm  as  the  cause,  except  in  the  case  of  a  pulsating 
empyema.  This  may  be  distinguished  by  its  greater  distance  from 
the  median  line  than  aneurysm,  and  by  its  being  usually  on' the  left 
side,  with  extensive  dulness  on  percussion  at  the  base  of  the  lung. 

It  is  in  the  abdominal  cavity,  however,  that  abnormal  pulsations 
abound  fully  ten  times  as  often  as  in  the  thorax.     They  may  occasion 


252  CLINICAL   MEDICINE 

such  distress  as  to  interfere  with  sleep,  while  the  throbbing  may  be  so 
situated  as  very  naturally  to  suggest  aneurysm.  But  mistaken  diag- 
noses about  abdominal  aneurysms  are  the  rule,  because  not  only  are 
none  present  in  the  great  majority  of  cases,  when  so  supposed,  but 
Bryant^  states  that  at  Guy's  Hospital,  out  of  54  cases  of  abdominal 
aneurysm,  only  18  were  correctly  diagnosed  during  life  by  its  able  staff. 
Hence,  it  is  serviceable  to  note  than  an  abdominal  aneurysm  is  rela- 
tively not  a  common  affection,  the  average  incideace  being  10  in  the 
thorax  to  i  in  the  abdomen,  while  in  women  abdominal  aneurysms  are 
extremely  rare.  Abdominal  pulsation,  on  the  contrary,  is  much  more 
common  in  women  than  in  men. 

One  form  of  such  pulsation,  which  may  be  very  strong  and  plainly 
visible  in  the  epigastrium,  is  caused  by  transmission,  through  the  left 
lobe  of  the  liver,  of  the  impulse  of  a  dilated  right  ventricle,  but  some- 
times a  greatly  dilated  right  ventricle  will  itself  lift  the  ensiform  carti- 
lage and  the  skin  over  it  into  the  semblance  of  a  pulsating  tumor. 

The  toxemia  which  causes  hysteria  often  selects  the  vasoconstric- 
tors of  the  great  splanchnic  arteries  to  produce  in  them  local  paralysis 
or  local  spasm.  One  effect  of  such  paralysis  is  the  supervention  of 
polyuria.  I  had  a  patient  who  every  morning  for  two  years  passed, 
with  a  sense  of  much  internal  throbbing,  100  ounces  or  more  of  color- 
less urine,  sometimes  with  the  specific  gravity  of  spring  water,  to  be 
followed  in  the  evening  with  a  few  ounces  of  urine  perfectly  normal  in 
color  and  in  specific  gravity.  In  other  cases  spasm  causes  anuria  in- 
stead of  polyuria.  Such  patients  are  called  neurotic  erroneously,  for 
the  nervous  system  is  not  at  fault  in  them  any  more  than  it  is  in  a 
drunkard,  but  their  blood  poisons  not  only  cause  a  great  variety  of 
nervous  symptoms,  but  sometimes  the  abdominal  aorta  In  them 
may  be  felt  pulsating  most  violently  with  both  a  thrill  and  a  bruit. 

Inflammatory  or  ulcerative  conditions  in  the  mucous  membrane 
of  the  gastro-intestinal  tract  are  always  accompanied  by  arterial 
throbbing  in  the  regions  affected.  In  suspected  gastric  ulcer,  pulsation 
should  be  looked  for,  though,  if  found,  its  locahty  may  not  closely 
correspond  to  the  seat  of  the  lesion  in  the  stomach.  In  some  forms  of 
cancer  of  the  stom-ach,  especially  in  the  large  flat  variety,  pulsation  is 
often  very  pronounced.  In  acute  enteritis  the  pulsation  is  quite 
pronounced,  usually  at  the  left  of  the  umbilicus,  and  always  to  be  found 
in  acute  coHtis,  and  is  then  most  commonly  due  to  throbbing  of  the 
mesenteric  arteries. 

One  of  the  commonest  causes  of  widespread  arterial  pulsation  is  a 

1  Clinical  Journal,  1903. 


EXAMINATION    OF   THE    BLOOD-VESSELS  253 

watery  state  of  the  blood;  hence  we  had  it  in  most  forms  of  anemia, 
where  pulsation  may  be  present  not  only  in  the  arteries,  but  also  in 
the  large  veins.  Sudden  hemorrhage  in  the  abdominal  cavity  is  some- 
times the  cause  of  the  most  extraordinary  throbbing.  Osier ^  reports 
a  case  of  a  large,  stout  man,  aged  forty-five  years,  who  when  seen 
by  him  was  anemic,  and  looked  as  if  he  had  had  a  recent  hemor- 
rhage. His  large  and  fat  abdomen  throbbed  in  a  most  extraordinary 
way.  The  shock  was  communicated  to  the  patient's  body,  and  one 
could  plainly  see  the  jar  in  the  head  and  in  the  feet.  Standing  against 
the  foot  of  the  bed.  Dr.  Osier  could  feel  distinctly  the  impulse  jarring 
the  entire  bed.  That  evening  the  cause  of  the  sudden  anemia  became 
evident  as  he  passed  a  large  amount  of  blood  by  the  bowel  and  vomited 
blood.  The  necropsy  showed  a  duodenal  ulcer  lying  directly  upon  the 
pancreas  and  the  aorta.     The  aorta  itself  was  perfectly  normal. 

In  Graves'  disease  arterial  pulsation  is  visible,  not  only  in  the 
arteries  of  the  neck,  but  sometimes  in  all  the  arteries  that  can  be  seen, 
as  we  might  expect  from  the  specific  effect  of  the  toxin  of  this  disease  in 
producing  paralysis  of  the  vasoconstrictors.  Some  of  the  greatest 
difficulties  in  diagnoses  of  the  cause  of  abdominal  pulsation  are  due  to 
transmission  of  the  arterial  throb  through  tumors,  such  as  cysts  or 
solid  tumors  of  the  pancreas,  mesentery,  and  retroperitoneal  glands. 
When  these  tumors  form  attachments  to  the  arteries,  differential  diag- 
nosis from  an  aneurysm  may  be  impossible,  because  they  may  have  a 
distinct  bruit,  and  it  is  not  always  easy  to  determine  in  abdominal 
tumors  whether  they  are  expansile  or  not. 

Veins. — The  veins  of  the  backs  of  the  hands  most  readily  afford 
evidence  of  general  conditions  affecting  the  venous  flow.  These  may 
be  habitually  distended  in  states  of  muscular  or  nervous  debihty,  espe- 
cially when  the  hands  hang  down.  It  is  in  gouty  states  of  the  blood, 
however,  that  this  sign  is  most  useful.  For  example,  when  in  doubt 
whether  an  arthritis  be  gouty  or  rheumatic,  it  is  not  rheumatic  if  the 
veins  about  the  joint  are  distended,  as  well  as  the  veins  on  the  backs 
of  the  hands.  This  sign  in  the  hands  may  also  be  confirmatory  of 
other  signs  of  lead-poisoning,  as  a  gouty  condition  of  the  system  is 
then  very  common.  Enlargement  of  the  veins  about  any  diseased 
joint  rules  out  rheumatism,  for  however  chronic  a  rheumatic  inflam- 
mation be  it  does  not  distend  veins. 

LocaHzed  phlebitis  may  often  be  recognized  in  t3^hoid  fever,  when 
it  most  commonly  affects  the  saphenous  vein  near  the  groin.  The  vein 
then  becomes  hardened  and  very  tender  to  pressure.     If  seen  early,  the 

1  Lecture  on  Aneurysm  of  the  Abdominal  Aorta,  Lancet,  October  14,  1905- 


254  CLINICAL  MEDICINE 

phlebitis  may  be  arrested  by  painting  the  track  of  the  vein  with  strong 
tincture  of  iodin.  It  is  in  chlorosis,  however,  that  such  locaHzed  phle- 
bitis may  occur  successively  in  widely  distributed  localities. 

Otherwise,  enlargement  of  the  veins  has  a  local  origin  and  may  be  of 
great  value  in  diagnosis  of  the  particular  organ  or  structure  which  is 
affected.  In  some  instances  the  signs  of  the  venous  obstruction  indi- 
cate just  what  has  happened,  if  not  also  the  nature  of  the  disease  which 
causes  the  engorgement. 

Varicose  veins  of  the  leg  imply  nothing  but  a  local  abnormaHty, 
generally  owing  to  congenital  developmental  defects  in  the  venous 
valves  analogous  to  those  defects  in  the  inguinal  canal  which  lead  to 
hernia.  They  are,  therefore,  often  family  complaints,  but  may  second- 
arily arise  from  too  prolonged  standing,  just  as  hernia  may  first  occur 
after  strain  of  the  abdominal  muscles.  The  branches  of  the  internal 
saphenous  vein  are  the  oftener  affected,  and  appear  most  on  the  inner 
aspect  of  the  calf.  Much  less  commonly  the  external  saphena  is  in- 
volved, appearing  on  the  outer  side  and  posteriorly.  The  strain  of 
the  unsupported  column  of  blood  produces  the  same  effects  as  strain 
in  arteries,  for  the  walls  of  the  veins  become  thickened  and  atheromat- 
ous, and  even  calcified;  but  the  significance  of  this  vascular  change 
wholly  differs  in  the  two  cases,  for  a  thickened  artery  impHes  general 
arterial  disease  and  not,  Hke  varicose  veins,  limited  to  the  legs.  Hence, 
the  indication  for  treatment  of  varicose  veins  is  to  furnish  external 
support  by  bandages  or  elastic  stockings.  Care  should  be  taken,  how- 
ever, not  to  confound  with  this  trouble  the  very  different  condition 
of  the  venou  scirculation  of  a  leg  in  which  the  deep  femoral  veins 
or  venae  comites  have  been  obstructed.  This  occurs  in  the  phlegma- 
sia alba  dolens  or  milk  leg  of  parturient  women,  in  whom  it  may  be 
for  years  after  their  recovery  that  the  affected  leg  remains  heavy, 
swollen,  and  stiff.  In  them  the  surface  veins  become  enlarged  com- 
pensatory to  the  obhteration  of  the  deeper  veins,  but  their  appearance 
differs  from  varicose  veins  in  being  smaller,  and  with  stellate  radiations 
under  the  skin  from  the  larger  vessels.  In  such  patients  tight  bandag- 
ing, by  interfering  with  the  collateral  circulation,  increases  the  pain  in 
the  leg. 

It  is,  however,  in  disease  or  tumors  involving  important  organs  in 
the  great  cavities  of  the  abdomen  and  thorax  that  enlargement  of  the 
surface  veins  most  commonly  afford  evidence  of  the  internal  mischief. 
Thus,  the  most  pronounced  appearances  of  enlarged  and  tortuous  veins 
on  the  surface  of  the  abdomen  are  to  be  seen  when  cancers  or  sarco- 
matous tumors  of  the  Kver,  pancreas,  or  kidney  encroach  upon  the 


EXAMINATION    OF    THE    BLOOD-VESSELS  255 

ascending  vena  cava.  But  it  is  in  cirrhosis  of  the  hver  that  we  most 
often  find  compensatory  enlargement  of  the  surface  veins,  though  not 
so  tortuous  as  in  the  last  case.  One  set  of  these  veins  belong  to  the 
accessory  portal  system  of  Sappey,  whose  branches  pass  in  the  round 
and  suspensory  ligaments  and  unite  with  the  epigastric  and  mammary 
systems.  Occasionally,  one  finds  a  large  single  vein  of  this  system 
joiaing  the  epigastric  veins  at  the  navel,  having  followed  the  situation 
of  the  obliterated  umbilical  vein.  This  produces  about  the  navel  a 
bunch  of  varices,  the  so-called  caput  medusae.  Another  communica- 
tion occurs  between  the  hemorrhoidal  and  inferior  mesenteric  veins, 
when  they  become  merged  with  a  larger  flow,  distending  the  veins  of 
the  surface  on  account  of  the  pressure  of  ascites  interfering  with  the 
flow  of  venous  blood,  from  the  lower  extremities  through  the  iliac  veins. 
This  causes  the  veins  to  appear  as  if  ascending  from  the  neighborhood 
of  Poupart's  Hgament,  the  blood  then  taking  its  course  through  the 
inferior  and  superior  epigastric  veins  to  the  mammary  veins. 

But  it  is  organic,  changes  occurring  in  the  thorax  which  produce 
the  most  pronounced  and  distinctive  derangements  of  the  venous 
circulation.  This  is  particularly  the  case  w^hen  the  primar}^  seat  of  the 
disorder  Kes  in  that  space  between  the  two  lungs,  called  the  mediasti- 
num. So  many  vital  organs  are  packed  together  in  that  space  behind 
the  sternum  that  it  is  well  for  every  one  to  be  able  to  enumerate  them. 
Setting  aside  the  heart  and  pericardium,  we  have  what  remains  of  the 
thymus  gland:  the  arch  of  the  aorta  and  its  descending  portion,  with 
the  innominate  and  commencement  of  the  left  carotid  and  subclavian 
arteries;  the  superior  vena  cava,  innominate,  and  azygos  veins,  and  the 
termination  of  the  inferior  vena  cava  within  the  pericardium  before 
it  enters  the  right  auricle;  the  pulmonary  vessels;  the  trachea  and  its 
bifurcation  with  the  main  bronchi;  the  pneumogastric  nerves,  with  the 
left  recurrent  laryngeal  and  cardiac  branches,  phrenic  and  splanchnic 
nerves,  and  the  cardiac  plexuses ;  the  roots  of  the  lungs,  including  the 
pulmonary  vessels  and  bronchi  with  their  primary  divisions,  and  the 
anterior  and  posterior  pulmonary  plexuses ;  the  esophagus ;  the  thoracic 
duct,  and  whole  sets  of  particular  lymphatic  glands.  Between  all 
these  parts  there  is  a  packing  of  loose  cellular  tissue,  which  may  also 
share  in  the  production  of  derangements.  On  that  account,  one  of  the 
commonest  accompaniments  of  new  growths  in  the  mediastinum  is  the 
appearance  of  many  enlarged  and  tortuous  veins  on  the  surface  of  the 
chest. 

As  the  mediastinum  is  not  a  \nscus,  it  is  scarcely  correct  to  speak 
of  a  mediastinitis,  except  with  a  hmitation  sanctioned  by  usage  of  the 


256  CLINICAL   MEDICINE 

term  to  inflammation  of  tlie  mesh  of  connective  tissue  between  the 
various  organs.  This  may  be  due  to  an  extension  from  an  inflamed 
pericardium;  but  also  the  pleural  surfaces,  a  reflection  of  which 
surfaces  bound  this  space  on  each  side  back  to  the  roots  of  the  lungs, 
may  participate  in  the  process.  Sometimes  in  chronic  mediastinitis 
all  the  contained  organs  are  found  at  autopsies  so  matted  together 
that  they  cannot  be  separated,  and  have  to  be  removed  en  masse.  It 
can  readily  be  inferred  that  in  such  cases  before  death  all  the  veins 
forming  branches  of  the  descending  cava  are  enlarged,  with  occa- 
sionally, as  I  have  seen,  enlargement  of  the  surface  abdominal  veins, 
with  ascites  from  impUcation  of  the  ascending  cava  as  it  enters  the 
pericardium. 

Mediastinal  tumors,  whether  aneurysmal  or  mahgnant,  may  cause 
the  same  appearances  of  venous  engorgement.  When  the  superior 
vena  cava  is  affected,  the  whole  head,  face,  ears,  neck,  and  botji  arms 
become  swollen.  On  the  surface  of  the  chest  the  mammary  and  supe- 
rior epigastric  veins  are  enlarged  and  very  tortuous-like  varices.  The 
intercostal  and  subcutaneous  veins  near  the  spine  may  also  be  dilated, 
which  is  suggestive  of  occlusion  of  the  vena  azygos. 

This  appearance  of  the  veins,  however,  occurs  usually  earlier,  and 
is  more  pronounced  with  malignant  growths  than  in  aneurysms  or 
other  intrathoracic  tumors,  so  as  to  be  of  some  use  in  diagnosis,  prob- 
ably because  aneurysms  simply  push  aside  contiguous  structures, 
while  mahgnant  growths  directly  attack  and  invade  them. 

Much  the  commonest  cause,  however,  of  visible  enlargement  of 
veins  is  organic  change  in  the  right  heart,  when,  though  the  surface 
veins  of  the  chest  are  not  much  altered,  the  veins  of  the  neck  and 
head  are  so  characteristically  affected  as  to  merit  close  observation. 
Occasionally  the  heart  is  dilated  by  external  traction  upon  it  by  peri- 
cardial adhesions  to  contiguous  structures.  But  the  commonest 
cause  of  venous  engorgement  occurs  in  the  pulmonary  circulation, 
which  may  be  primary,  as  in  emphysema,  or  secondary,  to  mitral  valve 
disease  of  the  left  heart,  particularly  mitral  stenosis.  The  right  heart, 
accordingly,  first  hypertrophies  and  then  dilates,  until  the  tricuspid 
valves  become  so  incompetent  that  backward  regurgitation  occurs 
with  each  systole  into  both  the  ascending  and  descending  cava. 
This  causes  a  true  pulsation  to  be  visible  in  the  veins  of  the  neck,  par- 
ticularly in  the  right  internal  jugular,  as  this  vessel  descends  in  a  direct 
hne  to  the  innominate  vein.  Therefore  a  visible  pulsation  in  the  veins 
of  the  neck  is  a  sure  sign  that  the  right  heart  no  longer  effectively  for- 
wards the  blood  through  the  lungs.     Occasionally,  instead  of  pulsa- 


THE   PULSE  257 

tion  above  in  the  neck,  a  pulsating  tumor  like  a  ball  is  seen  at  the  junc- 
tion of  the  jugular  and  subclavian  veins.  This  happens  when  the 
valves  in  both  the  jugular  and  subclavian  veins  are  competent  enough 
to  prevent  further  regurgitation  from  the  right  heart. 

DISEASES  OF  THE  CAPILLARIES 

The  most  important  parts  of  the  circulation  are  those  tubes  which 
intervene  between  the  ends  of  the  arteries  and  the  beginning  of  the 
veins,  and  which,  from  their  small  size,  are  called  capillaries.  It  is 
through  them  that  the  interchange  occurs  both  of  the  fluids  and  of 
the  gases  like  oxygen,  which  nourishes  the  tissues  and  the  materials 
that  are  returned  to  the  circulation  of  the  same  regions.  As  a  rule, 
the  capillaries  are  of  the  same  diameter,  but  the  interspaces  between 
them  vary  according  to  the  vascularity  of  the  part.  Sometimes  the 
interspaces  are  actually  smaller  than  the  diameter  of  the  capillaries, 
but  in  known  vascular  parts  they  may  be  a  good  deal  larger.  In 
structure  they  consist  of  a  layer  of  epithehoid  cells,  usually  placed 
•end  to  end,  and  which  may  be  considered  a  prolongation  of  the  in- 
tima  of  the  smallest  arteries.  These  cells  are  bound  together  by  a 
cement-like  substance.  The  walls  of  the  capillaries  are  so  thin  that 
they  allow  an  easy  passage  through  them  of  nutrient  fluids,  and  also 
of  fluids  containing  the  used-up  materials  of  the  tissues.  They  also 
allow  in  certain  regions  the  white  corpuscles  to  pass  through  the 
walls  in  both  ways.  It  is  evident  from  what  has  preceded  that  the 
process  of  arteriosclerosis,  above  described,  also  extends  into  the 
domain  of  the  capillaries,  causing  widespread  obhteration,  a  change 
never  absent  in  general  arteriosclerosis,  which,  as  we  have  remarked, 
at  any  time  may  be  demonstrated  in  the  skin  of  the  abdomen  by 
drawing  the  finger-nail  over  it.  In  young  and  normal  tissues  this 
procedure  readily  leaves  a  red  mark,  as  we  have  described,  which  is 
absent  in  all  conditions  of  vascular  sclerosis. 

THE  PULSE 

Every  physician  is  as  much  accustomed  to  feel  the  pulse  as  to  look 
at  the  tongue,  but  both  these  procedures  may  be  performed  in  a 
wholly  routine  manner  without  much  thought  accompanying  it.  To 
prevent  this,  we  would  here  briefly  indicate  what  should  be  carefully 
observed  in  every  examination  of  the  pulse. 

For  ordinary  purposes  six  elements  should  be  noted  in  the  pulse, 
three  of  them  being  exclusively  caused  by  the  action  of  the  heart 
and  three  of  them  by  the  condition  of  the  artery.     The  first  cardiac 

17 


258  CLINICAL  MEDICINE 

element  is  frequency,  for,  whether  the  pulse  be  rapid  or  slow,  it  is 
caused  by  the  rapid  or  slow  contraction  of  the  left  ventricle;  the 
second  cardiac  element  is  strength,  for  that  depends  upon  the  ventricle 
beating  strongly  or  feebly;  the  third  is  rhythm,  that  is,  whether  the 
heart  is  beating  regularly  or  irregularly.  The  first  vascular  or  arterial 
element  is  size,  or  whether  the  pulse  feels  full  or  small;  the  second 
vascular  element  is  quality,  that  is,  whether  the  pulse  is  hard  or 
soft,  ordinarily  termed  "incompressible"  or  "compressible";  the  third 
vascular  element  is  duration,  that  is,  whether  the  pulse- wave  passes 
quickly  under  the  finger  or  is  more  or  less  prolonged,  commonly 
denoted  as  a  short  or  long  pulse. 

These  are  elements  which  every  physician  should  learn  to  dis- 
tinguish by  his  own  practised  sense  of  touch.  Among  these  characters 
of  the  pulse,  which  are  recognized  by  the  sense  of  touch,  is  one  that  is 
always  of  pathologic  import,  namely,  dichrotic  pulse,  commonly  found 
in  the  early  stages  of  typhoid  fever.  To  the  observer  it  feels  as  if 
he  had  two  pulses,  the  first  and  the  stronger  wave  being  the  ordinary 
systohc  pulse,  caused  by  the  contraction  of  the  left  ventricle.  This  is 
immediately  followed  by  a  feebler  wave,  which  is  due  to  a  reflux  from 
the  periphery. 

As  to  frequency,  it  may  mean  only  nervous  excitement,  in  which 
case  it  soon  subsides;  it  may  mean  the  presence  of  fever;  in  all 
fevers,  if  they  be  prolonged,  the  pulse  is  apt  to  be  much  increased  in 
frequency,  as  in  phthisis;  or,  it  may  be  due  to  exhaustion;  thus  in  a 
convalescent  from  typhoid  fever  the  pulse  may  be  slow  while  the 
patient  is  recumbent,  but  quickly  rises  in  frequency  if  the  patient  sits 
up.  It  is  then  important  to  note  how  much  the  change  of  posture  has 
increased  the  frequency,  for  in  health  this  change  of  posture  should 
only  increase  the  pulse-rate  from  5  to  15  beats.  But  if,  instead,  it 
increases  it  from  20  to  40  beats  the  patient  should  not  yet  be  allowed 
to  sit  up,  for  fatal  syncope  has  often  followed  from  neglect  of  this 
precaution.  A  frequent  pulse,  however,  may  occur  in  other  conditions, 
as  in  Graves'  disease  and  in  tabes,  but  in  neither  of  these  states  is  the 
rate  of  the  pulse  altered  by  change  of  posture. 

As  to  strength,  this  is  ordinarily  increased  in  the  first  stage  of  all 
acute  inflammations,  such  as  pneumonia,  and,  besides  the  pulse,  the 
force  of  the  impulse  of  the  heart  against  the  chest  wall  should  be  noted ; 
when,  instead,  the  pulse  is  weak,  the  causes  of  its  weakness  should  be 
carefully  determined.  And  here,  again,  in  pronounced  cases  the  heart 
impulse  may  be  scarcely  perceptible;  the  weakness  may  be  due  to 
debiHty  of  the  heart  wall,  the  causes  of  which  should  be  clearly  dis- 


THE   PULSE  259 

tinguished;  the  pulse  may  be  fairly  strong,  but  the  impulse  be  absent 
in  cases  of  emphysema;  the  impulse  may  be  weak  and  yet  diffused 
in  cases  of  dilatation;  or  the  heart  may  be  weak  from  exhaustion  in 
cases  of  prolonged  fever,  each  of  which  conditions  may  require  special 
treatment. 

As  to  rhythm,  a  distinction  should  be  made  between  an  intermittent 
and  an  irregular  pulse;  an  irregular  pulse  is  always  a  sign  of  disease, 
while  an  intermittent  pulse  may  coincide  with  good  health.  I  have 
known  persons  in  excellent  health,  who  presented  a  regularly  intermit- 
tent pulse,  dropping  every  fourth  or  fifth  beat;  or  an  intermittent  pulse 
may  be  caused  by  too  free  indulgence  in  tea  or  tobacco,  as  well  as  by 
some  medicines,  of  which  digitahs  is  an  example.  In  the  case  of  digi- 
talis the  supervention  of  an  intermittent  pulse  should  lead  to  cessation 
of  its  administration,  for  it  may  cause  severe  vomiting  and  collapse, 
which  may  be  relieved  by  a  full  dose  of  opium.  An  irregular  pulse,  on 
the  other  hand,  is  characterized  by  derangement  both  of  frequency 
of  ryhthm  and  of  size,  and  is  present  in  conditions  of  dangerous  exhaus- 
tion or  of  actual  heart  disease. 

As  to  its  vascular  elements,  the  pulse  is  full  and  large  in  the  first 
stages  of  all  inflammations  excepting  peritonitis.  It  is  small  in  anemia, 
excepting  chlorosis;  in  all  conditions  of  weakness,  such  as  the  later 
stages  of  prolonged  fevers.  In  scarlet  fever  the  pulse  is  strikingly 
small  and  of  high  tension  from  the  beginning. 

Between  these  different  characters  of  the  pulse,  relatively,  the  most 
important  is  its  tension.  We  have  already,  in  speaking  of  arterio- 
sclerosis, shown  the  great  significance  of  the  pulse  with  permanent  high 
tension.  The  degree  of  this  tension  the  finger  alone  cannot  accurately 
determine,  and  so  a  number  of  different  sphygmomanometers  have 
been  devised,  which  need  not  be  enumerated  here.  To  become  really 
adept  in  their  use  requires  much  practice,  and,  therefore,  when  in 
doubt,  I  am  accustomed  to  refer  many  cases  to  the  reports  of  an 
expert. 

As  to  duration,  the  pulse  is  long  in  all  cases  of  high  tension,  and  is 
characteristically  short  in  some  inflammations,  notably  in  cystitis, 
when  this  character  of  the  pulse  may  be  diagnostic. 

Stokes-Adams'  Disease,  or  Heart-block. — The  impulse  causing  the 
heart  to  beat  originates  at  the  venous  end  of  the  heart,  and  is  trans- 
mitted in  such  a  way  that  the  auricles  contract  first,  the  ventricles 
a  moment  later,  the  impulse  being  propagated  like  a  peristaltic  wave 
through  the  heart  walls.  "This  is  by  means  of  a  muscular  strand;  in 
the  adult  heart  this  auriculoventricular  bundle  of  His,  as  it  is  called. 


26o  CLINICAL  MEDICINE 

arises  in  the  septum  of  the  auricles  below  the  foramen  ovale,  and  passes 
downward  through  the  trigonum  fibrosum  of  the  auriculoventricular 
junction,  where  it  comes  into  close  relation  with  the  mesial  leaflet  of 
the  tricuspid  valve"  (Osier).  Recent  researches  show  that  its  fibers 
extend  even  to  the  apex  of  the  heart.  Disease  or  atrophy  of  this 
bundle  of  His  prevents  the  contraction  of  the  auricle  from  being  con- 
tinued to  the  ventricle,  and  the  ventricle  then  contracts  and  relaxes 
independently,  with  the  slowing  of  the  pulse  at  the  wrist.  I  had  a 
patient  in  whom  I  never  could  succeed  in  increasing  his  pulse-beat 
above  36,  while  usually  it  remained  about  30.  His  symptoms  were 
very  characteristic  of  this  condition.  He  had  frequent  epileptiform 
attacks,  when  he  would  fall  to  the  ground  with  a  transient  loss  of  con- 
sciousness. Under  treatment  by  grain  doses  of  powdered  squills  with 
^  gr.  of  strychnin,  he  recovered  from  these  attacks  and  was  able 
to  resume  his  business,  but  I  never  succeeded  in  causing  the  ventricle 
to  contract  as  rapidly  as  his  auricle.  Cases  much  resembhng  Stokes- 
Adams'  disease  in  effect  on  the  pulse  sometimes  occur  in  elderly  people 
with  general  arterial  disease,  that  is,  they  have  attacks  of  uncon- 
sciousness with  epileptiform  twitchings,  but  are  soon  relieved  by  squills, 
strychnin,  sodium  iodid,  and  my  tonic  prescription  of  iron  and  car- 
bonate of  ammonia.  (See  page  284.)  In  all  cases  of  slow  pulse  the 
frequency  of  the  beats  of  the  heart  with  the  radial  pulse  should  be 
noted,  because  it  may  be  that  the  systole  of  the  ventricle  is  not  strong 
enough  to  reach  the  wrist. 

ARTERIOSCLEROSIS 

"The  blood  thereof  which  is  the  Hfe  thereof"  is  a  statement  very 
fully  illustrated  by  the  pathology  of  any  part  of  the  body  the  supply 
of  whose  blood  is  interfered  with  by  a  diseased  condition  of  its  blood- 
vessels. The  first  result  of  such  interference  is  a  loss  of  vitality  in  the 
part,  directly  proportional  to  the  degree  of  this  interference.  If  it 
be  complete,  necrosis  or  gangrene  forthwith  follows,  but  if  partial, 
then  vitality  continues,  but  lessens  in  simple  proportion  to  the  inter- 
ference with  the  circulation.  Old  age  is  a  natural  disease  of  our  race, 
and  its  pathology  is  almost  wholly  that  of  aging  of  the  blood-vessels, 
because  that  induces  senility  of  all  the  muscles,  causing  them  to  atrophy 
and  to  become  stiff;  likewise,  senility  of  the  glands  and  general  senility 
of  nutrition,  shown  in  the  wrinkled  skin  and  whitened  hair. 

But  the  process  of  growing  old  varies  greatly  in  different  individuals. 
Nowhere  is  the  jocose  advice  so  appHcable  that  one  should  be  partic- 
ular in  the  choice  of  his  parents,  because  the  Ufe  of  the  arteries  depends 


ARTERIOSCLEROSIS  26 1 

first  on  heredity.  Some  persons'  arteries  are  as  old  at  forty  as  those 
of  others  at  threescore  years  and  ten.  The  chief  aim  of  a  physician, 
therefore,  is  not  to  prevent  the  inevitable,  ending  in  death,  but  to  post- 
pone it,  and  for  that  we  should  study  what  parts  of  the  vascular 
apparatus  are  diseased. 

Arterial  Structure. — Preliminary  to  the  consideration  of  the  dif- 
ferent forms  of  arterial  disease  we  should  have  a  clear  picture  of  the 
structure  of  these  blood-vessels.  An  artery  is  composed  of  three  coats, 
the  inner  one,  or  the  intima,  Hnes  the  whole  vessel,  from  its  beginning 
in  the  aorta  to  its  finest  divisions  of  the  arterial  tree.  This  intima  in 
health  is  smooth,  composed  first  of  an  epithelial  lining  of  polygonal 
or  fusiform  cells.  Under  the  epithelium  are  layers  of  delicate  elastic 
tissue,  which  increase  with  the  size  of  the  artery  until  they  form  the 
greater  part  of  the  intima  in  the  aorta.  The  intima  is  subject  to 
changes  when  the  artery  becomes  diseased.  One  change,  which  is 
rather  compensatory  than  otherwise,  is  described  by  Thoma  as  the 
deposition  of  a  hyaline  material  noticeable  in  the  lining  of  the  larger 
arteries.  He,  by  injecting  the  aorta  and  large  arteries  with  paraffin 
wax  at  a  pressure  of  i6o  mm.  of  mercury  (the  mean  pressure  in  the 
aorta),  has  shown  that  the  paraffin  casts  are  quite  smooth,  and  present 
none  of  the  irregularities  which  the  nodular  plaques  would  have 
produced  had  they  not  exacly  filled  up  the  bulge  in  the  vessel  wall, 
produced  by  the  weakened  media,  at  the  spots  where  the  intima  is 
thickened.  Certainly,  this  is  a  strong  argument  in  favor  of  his  compen- 
satory view. 

But  aside  from  that,  changes  occur  in  the  intima  which  are  undoubt- 
edly pathologic.  These  are  the  first  patches,  which  look  almost  like 
simple  depositions  in  the  walls  of  the  intima,  with  a  pale  yellowish 
color.  In  time  these  increase  in  thickness  as  well  as  in  extent,  and  un- 
dergo a  species  of  fatty  degeneration  called  atheroma,  notably  in  the 
aorta  and  larger  branches.  In  these  atheromatous  patches  there  may 
further  occur  extensive  deposits  of  Hme  salts,  or  the  condition  called 
calcification.  Besides  this,  longitudinal  shts  may  occur  in  the  intima, 
some  of  which  terminate  in  ulcerative  processes  that  involve  the 
other  coats,  thus  leading  to  aneurysms  that  may  be  of  small  size,  but, 
nevertheless,  very  serious  if  they  occur  in  the  cerebral  arteries,  as  they 
then  occasion  attacks  of  cerebral  hemorrhage.  Such  arterial  changes 
may  be  very  extensive,  involving  the  smaller  arteries,  and  thus  consti- 
tuting the  first  stage  in  the  widespread  disease  called  arteriosclerosis. 
This  condition  has  been  well  defined  by  F.  W.  Mott  as  ''a  local  or  gen- 
eral thickening  of  the  arterial  wall  with  loss  of  contractility  and  elas- 


262  CLINICAL  MEDICINE 

ticity  occasioned  by  fibrous  overgrowths,  mainly  of  the  tunica  intima, 
secondary  and  proportional  to  degeneration  of  the  muscular  and  elastic 
elements  of  the  media." 

The  most  Hving  part  of  an  artery  is  the  middle  coat,  as  it  contains 
a  muscular  layer  whose  cells  are  in  connection  with  a  very  peculiar, 
but  most  important,  division  of  the  nervous  system,  called  the  vaso- 
motor nerves.  The  fibers  of  the  middle  coat  are  transverse  instead 
of  longitudinal,  as  in  the  intima.  It  is  composed  of  two  layers,  the 
first  of  which  is  the  elastic  tissue,  which  wholly  predominates  in  the 
aorta  and  the  larger  arteries,  and  the  second  is  the  muscular  layer,  which 
is  of  a  different  and  reddish  color.  This  muscular  layer  proportion- 
ately increases  from  the  medium  to  the  smaller  arteries  until,  in  the 
smallest  arteries,  it  constitutes  the  chief  elements  in  the  walls  of  the 
vessels. 

The  adventitia,  or  outer  coat,  is  made  up  by  a  condensation  of 
connective  tissue  mingled  with  layers  of  elastic  fibers.  The  vasomotor 
nerves  form  a  dense  plexus  upon  the  coats  of  the  medium-sized  arteries, 
and  then  accompany  these  vessels  down  to  the  smallest  of  them,  which, 
however,  may  have  but  a  single  nerve-filament.  The  function  of 
these  vasomotor  nerves  is  to  regulate  the  distribution  of  blood  both 
by  contracting  and  by  dilating  the  arteries,  according  to  the  needs  of 
the  part.  Like  other  branches  of  the  sympathetic ,  the  vasomotor  nerves 
form  small  gangUa,  situated  generally  at  the  bifurcation  of  the  ar- 
teries. At  the  other  end  of  this  system  there  is  what  is  called  the  vaso- 
motor center,  in  the  medulla  oblongata.  One  important  fact,  however, 
should  be  mentioned,  that  the  vasomotor  nerves  depend  for  their  ac- 
tivity upon  the  presence  in  the  blood  of  a  secretion  of  the  adrenal 
glands,  called  adrenalin.  When  these  glands  are  excised,  death  rapidly 
follows  from  a  total  loss  on  the  part  of  the  vasomotor  nerves  to  act 
according  to  their  proper  functions.  Absence  of  adrenahn  in  the 
blood  from  disease  of  the  glands  causes  that  malady  to  be  hereafter 
described  as  Addison's  disease,  but  there  can  be  no  doubt  that  the 
adrenals  are  also  capable  of  excessive  secretion,  which,  by  unduly 
contracting  the  arteries,  leads  to  high  pressure  or  strain  in  the  circu- 
lation, and  hence  must  be  one  cause  of  arterial  disease.  Athero- 
matous and  degenerative  changes  in  the  coats  of  the  arteries  are  de- 
pendent entirely  upon  the  amount  of  local  strain.  It  is  a  very  curious 
fact  that  originally  the  adrenal  glands  are  derived  from  a  branch  of 
the  sympathetic,  which  becomes  rolled  on  itself  like  a  ball  of  twine,  and 
then,  breaking  away  from  its  parent  stem,  it  takes  on  a  capsule,  and 
thus  becomes  the  adrenal  gland,  to  be  situated  upon  the  upper  extrem- 


ARTERIOSCLEROSIS  263 

ity  of  the  kidney,  with  which,  however,  it  has  no  anatomic  connec- 
tion. Arteriosclerosis,  as  a  general  morbid  process,  was  first  described 
by  Gull  and  Sutton,  who  extended  this  morbid  change  from  the  arteries 
into  the  domain  of  the  capillaries.  Arterial  disease  presents  numerous 
features,  many  of  which  are  not  yet  wholly  solved. 

Etiology. — As  to  etiology,  heredity  ranks  first,  as  previously  re- 
marked. The  consequent  changes,  however,  differ  according  to  the 
nature  of  the  tissue.  Thus,  brain  tissue  can  continue  to  perform  its 
mental  functions  years  after  the  arteries  of  the  body  have  become 
aged.  Gladstone  delivered  one  of  his  greatest  speeches  when  he  was 
eighty-six  years  old.  The  nervous  system,  being  the  royal  tissue, 
will  have  its  blood,  no  matter  what  happens  to  other  textures. 

As  already  remarked,  the  coats  of  the  aorta  and  of  the  larger 
arteries  are  pretty  sure  to  show  the  beginning  of  atheromatous  changes 
and  sclerotic  changes  in  middle  Hfe,  and  these  go  on  increasing  with  the 
years  until  arteriosclerosis  is  present  throughout  all  of  the  smaller 
blood-vessels.  The  vulnerabihty  of  the  arterial  tissue  to  strain  is  not 
surprising,  considering  that  not  only  does  a  ceaseless  rush  of  fluid  pass 
through  them  at  a  speed  of  lo  inches  a  second,  but  the  walls  of  the 
main  pipe  are  subjected  to  a  distending  force  of  2I-  pounds  to  the 
square  inch  60  to  80  times  a  minute,  80,000  to  100,000  times  in  the 
twenty-four  hours. 

The  special  morbid  process  begins  in  the  intima  and  then  involves 
more  or  less  the  other  coats.  The  changes  commence  in  the  intima, 
and  may  be  so  pronounced  as  actually  to  obliterate  the  lumen  of  the 
vessel,  but  usually  the  middle  coat  is  also  involved,  some  writers  main- 
taining that  the  muscular  layer  is  hyper  trophied  and  the  elastic  fibers 
increased,  but  these  changes  in  the  middle  coat  doubtless  vary  with 
different  individuals  and  at  different  times,  because  in  some  patients 
the  symptoms  of  spasm  come  and  go,  which,  of  course,  indicate  the 
participation  of  the  muscular  coat  in  their  production.  One  evi- 
dence of  this  is  consequent  high  pressure  of  the  pulse,  producing  in- 
creased strain  on  the  walls  of  the  vessel,  but  strain,  in  turn,  is  very  apt 
to  lead  to  atheromatous  degeneration,  as  we  find  this  latter  condition 
most  pronounced  in  those  regions  of  the  vessel  which  are  subject  to 
the  greatest  strain.  This  is  particularly  the  case  in  the  high  tension 
which  characterizes  chronic  interstitial  nephritis.  But  that  kidney 
disease  is  not  the  only  cause  of  either  atheroma  or  high  tension  is 
shown  in  a  number  of  cases  characterized  by  extensive  atheroma- 
tous changes  in  the  arteries,  and  yet  in  whom  there  is  neither  high 
pressure  nor  interstitial  nephritis. 


264  CLINICAL  MEDICINE 

Strain  in  the  circulation  must  also  vary  greatly  in  different  per- 
sons, particularly  in  those  who  are  subject  to  extreme  variations 
in  the  activities  of  modern  civilization.  When  we  consider  not  only 
how  changes  in  the  rapidity  and  force  of  the  blood-stream  must  pro- 
duce their  effects,  we  have  also  to  take  into  account  no  less  important 
factors  depending  upon  the  composition  of  the  blood  itself,  as  these 
may  be  affected  by  the  derangements  of  the  excreting  glands.  AU 
this  goes  to  prove  how  very  complex  the  problems  of  vascular  derange- 
ments must  be.  A  good  indication  of  the  general  state  of  the  circula- 
tion is  afforded  by  the  capillary  circulation  of  the  skin.  If  the  smaller 
arteries  are  permeable  and  the  blood-supply  to  the  skin  normal,  draw- 
ing the  back  of  the  nail  over  the  skin  is  at  once  followed  by  a  red 
mark.  If,  as  is  strikingly  illustrated  in  chronic  interstitial  nephritis, 
the  cutaneous  circulation  is  poor,  this  procedure  hardly  produces  any 
effect.  This  is  notably  the  case  in  the  loose  skin  of  the  abdomen, 
particularly  in  cases  of  cirrhosis  of  the  liver,  in  which  it  may  be  quite 
difficult  to  produce  any  red  streak  in  the  skin,  however  actively  the 
finger-nail  is  drawn  across  it.  Persons  in  such  conditions  are  very 
prone  to  be  carried  off  by  pulmonary  edema  in  pneumonia.  They 
are  also  pretty  sure  to  have  pulmonary  emphysema;  as  surgeons  well 
know  they  bear  operations  badly. 

Arteriosclerosis  imphes  obstruction  caused  by  roughening  of  the 
lumen  of  the  fining  of  the  vessel,  whether  by  atheroma  or  by  calcareous 
deposits.  This  leads  to  tortuosity  of  the  surface  arteries,  often  very 
strikingly  shown  in  the  crooked  temporal  arteries,  which  maybe  visible 
across  the  room.  / 

Besides  the  structural  changes  in  the  walls  of  the  arteries,  the 
diseased  arteries  are  themselves  prone  to  spasm  of  their  muscular 
coats,  which  often  is  quite  local.  Such  angiospasm,  as  it  is  called,  may 
temporarily  occur  in  widely  distributed  parts  of  the  body,  causing 
symptoms  whose  significance  every  physician  should  know,  as  they 
constitute  danger-signals.  Thus,  as  shutting  off  of  arterial  blood  al- 
ways causes  cramp  of  the  muscles  suppfied  by  that  artery,  so  cramp 
in  the  calf  of  the  leg  occurring  in  elderly  people  is  a  precursor  of 
apoplexy  due  to  angiospasm  in  the  cerebral  arteries.  Analogous 
angiospasm  in  the  cerebral  arteries  may  cause  transient  attacks  of 
giddiness  or  vertigo,  or  likewise  temporary  aphasia.  It  is  high  time, 
then,  for  the  use  of  the  sphygmograph  to  determine  the  presence  or 
not  of  high  blood-pressure.  These  facts,  which  we  have  been  review- 
ing, are  practically  of  great  importance  in  the  prophylaxis  or  prevention 
of  serious  calamities.    Thus,  as  we  have  before  remarked,  nerve  tissue 


ARTERIOSCLEROSIS  265 

is  not  at  fault  when  a  person  is  paralyzed  ?jy  an  attack  of  apoplexy 
or  of  hemiplegia.  It  is,  then,  not  nerve  tissue,  but  arterial  tissue  which 
is  diseased,  and  instead  of  considering  the  brain  we  should  most  likely 
turn  our  attention  to  the  kidneys  as  the  true  source  of  the  whole 
trouble. 

Treatment. — The  existence  of  widespread  arteriosclerosis  is  always 
of  serious  import,  but  the  outlook  is  by  no  means  hopeless.  We  are 
always  provided  with  an  oversupply  of  what  we  need  for  life,  thus 
we  have  two  kidneys,  when  any  one  may  get  along  very  well  for  years 
with  only  one  kidney.  Likewise,  everything  necessary  for  life  in  our 
arteries  is  much  in  excess  of  what  is  needed.  This  we  will  now  de- 
monstrate as  we  show  what  we  should  do  in  the  treatment  for  cases 
of  widespread  arteriosclerosis  with  high  blood-pressure.  As  these 
patients  commonly  have  shrunken  kidneys  from  chronic  interstitial 
nephritis,  the  kidneys  should  be  spared  as  much  as  possible  in  their 
work.  That  work  is  not  increased  by  a  diet  of  carbohydrates,  such  as 
in  starches  and  sugars  of  vegetables  and  fruits;  but  the  work  of  the 
kidneys  is  very  greatly  increased  when  they  have  to  deal  with  the 
nitrogenous  elements  of  the  food,  in  other  words,  with  meats.  Meat  of 
all  kinds,  therefore,  should  be  sparingly  used,  or  altogether  avoided, 
especially  at  the  evening  meals.  As  the  body  must  have  nitrogenous 
food,  this  can  be  best  supplied  by  the  various  preparations  of  fermented 
milk,  previously  explained  in  the  article  on  such  a  spasmodic  disease 
as  epilepsy. 

Medicinally,  we  have  extremely  valuable  agents,  which  act  as 
vasodilators.  Of  these  the  nitrites,  such  as  nitroglycerin  and  its 
allies,  are  well  known,  and  are  frequently  employed  for  this  purpose. 
But  the  disadvantage  of  all  nitrites  is  that  their  action  is  very  evan- 
escent. I  have,  therefore,  regarded  it  as  an  important  fact  to  be  widely 
known  that  we  possess  in  aconite  a  more  efficient  and  permanently 
beneficial  vasodilator.  The"oirly"a.gent  which  approaches  aconite  for 
this  purpose  is  veratrum  viride.  The  ofiicial  tincture  of  aconite  of  the 
Pharmacopeia  of  1890  should  be  prescribed  in  full  doses,  namely,  10 
drops  four  times  a  day,  and  continued,  it  may  be,  for  years.  There  need 
be  no  fear  of  the  primary  depression  of  the  heart  in  healthy  persons  by 
aconite,  because  the  relief  of  the  heart  by  dilatation  of  the  arteries 
quickly  overbalances  any  primary  depression  in  these  patients.  One  of 
the  most  indisputable  proofs  of  this  statement  is  shown  by  the  prompt 
increase  in  the  eh'mination  of  urea  by  kidneys  contracted  in  interstitial 
nephritis.  I  have  shown  in  several  published  articles  that  in  cases  of 
undoubted  shrunken  kidneys,  accompanied  with  all  their  characteristic 


266  CLINICAL  MEDICINE 

symptoms,  the  excretion  of  urea  has  by  the  administration  of  aconite 
been  doubled  or  trebled,  and,  in  a  few  cases,  quadrupled.  This  has  been 
my  experience  both  in  hospital  and  in  private  practice  for  many  years, 
a  ad  without  any  ill  effects  whatever.  For  example,  I  have  published  a 
case  which  I  saw  in  consultation  with  Dr.  Travis,  of  New  York,  of  a 
lady  aged  sixty-five,  who  could  not  be  turned  in  bed  without  losing 
color  in  the  hps  from  heart  failure,  who  was  immediately  and  per- 
manently relieved  by  the  above  doses  of  tincture  of  aconite,  simply 
because  her  exhausted  heart  was  by  the  aconite  set  free  from  contending 
with  general  arterial  contraction. 

Now,  increased  elimination  of  urea  found  by  examination  of  the 
urine  cannot  possibly  be  a  matter  of  theory,  and  the  restoration  of 
the  normal  function  of  the  kidneys,  so  far  as  possible,  is  the  first  indica- 
tion in  the  treatment  of  chronic  interstitial  nephritis.  But  imperfect 
elimination  ia  such  a  chronic  affection  as  interstitial  nephritis  may  be 
very  generally  observed  in  patients  who  go  about  their  business  with- 
out knowing  that  they  are  seriously  diseased  until  a  sudden  exposure 
of  symptoms  of  uremia  terminates  the  story.  I  therefore  found  the 
administration  of  aconite  as  above  detailed  invaluable  as  a  prophy- 
lactic. It  is  not  uncommon  also  to  find  that  patients  with  that  sad 
mental  derangement  of  melancholia  exhibit  a  high  blood-pressure,  and 
here  aconite  is  invaluable,  as  I  could  prove,  if  I  had  space,  by  the  his- 
tories of  such  patients. 

The  only  other  agent  which  I  would  mention  for  the  treatment  of 
arteriosclerosis  is  corrosive  sublimate,  given  in  doses  of  -^^  gr.  three 
times  a  day,  along  with  the  aconite,  for  I  have  known  this  agent  also 
to  increase  the  ehmination  of  urea. 

Moreover,  it  can  be  conjoined  with  5  gr.  of  the  sodium  iodid,  three 
times  a  day,  given  before  meals.  The  functions  of  the  skin  should  also 
be  carefully  attended  to  in  the  management  of  these  cases  It  is  well 
known  how  the  skin  supplements  the  work  of  the  kidneys,  for  free 
perspiration  in  warm  weather  invariably  lessens  the  output  of  water  by 
the  kidneys.  These  patients,  therefore,  do  better  in  summer  than  in 
winter,  particularly  as  in  summer  they  can  further  add  the  general 
dilatation  of  the  cutaneous  circulation,  which,  instead,  is  contracted 
during  cold  weather.  On  that  account  many  of  these  patients  when 
they  can  afford  it  do  better  if  the  winter  be  spent  in  warmer  climates. 
Speaking  generally,  careful  protection  of  the  skin  by  warmer  clothing 
is  indicated  in  the  cases  of  all  patients  who  suffer  from  arteriosclerosis. 


ANEURYSM  267 

ANEURYSM 

In  the  healthy  human  body  there  is  no  room  for  anything  but 
its  normal  organs  and  tissues,  hence  the  importance  of  anatomy, 
because  by  its  correct  knowledge  we  can  at  once  detect  what  ought  not 
to  be  there.  This  is  well  illustrated  in  the  case  of  aneur^^sms,  which 
cause  swellings  in  the  course  of  arteries  quite  distinct  from  growths, 
and  yet  which  chnically  may  produce  symptoms  scarcely  distinguish- 
able from  them.  In  discussing  the  causes  of  apoplexy  and  of  hcmo- 
plegia  we  mentioned  an  important  variety  of  aneury^sms  which,  though 
so  small  that  they  are  called  mihary  aneurysms,  are,  nevertheless,  as 
truly  aneurysms  as  those  which  form  great  tumors  in  the  course  of 
the  aorta,  because  the  definition  of  aneur\'sms  is  that  they  are  due  to 
a  lesion  in  one  or  in  two  of  the  three  coats  which  constitute  the  walls 
of  an  artery,  leaving  the  remaining  coat  or  coats  to  be  distended  by 
the  pressure  of  the  circulating  blood. 

Aneurysms,  therefore,  produce  symptoms  according  to  their  size 
and  location,  and  we  would  begin  with  the  aneurysms  of  the  aorta. 
The  first  of  these  we  would  refer  to  are  those  which  develop  just  above 
the  aortic  ring  and  the  sinuses  of  Valsalva.  They  are  usually  small 
and  are  generally  due  to  syphilis,  but  from  their  location  they  cause 
instant  death  by  bursting  into  the  pericardium.  Here  also  or  just 
above  them  may  begin  those  aneurysmal  changes  which  characterize 
the  different  forms  of  aneurysms  as  follows: 

(i)  The  dissecting  aneurysm,  which  results  from  injury  or  lacera- 
tion of  the  internal  coat.  The  blood  dissects  between  the  layers, 
hence  the  name  "dissecting  aneurysms."  This  occurs  usually  in  the 
aorta  and  may  last  for  years,  forming,  when  complete,  a  double  tube — 
the  so-called  double  aorta. 

(2)  Another  form,  due  to  weakening  of  the  coats  of  the  aorta,  causes 
the  ascending  portion  of  the  arch  to  be  uniformly  dilated. 

(3)  The  third  and  commonest  form  is  the  saccular,  which,  as  its  name 
implies,  forms  a  bag  more  or  less  large,  whose  open  mouth  connects 
with  the  circulating  blood.  These  sacs  may  be  so  large  as  to  occupy 
a  considerable  portion  of  the  thoracic  cavity.  In  the  course  of  their 
enlargement  they  may  come  in  contact  with  bone,  such  as  the  sternum 
or  the  ribs,  and  then  perforate  them.  How  such  a  soft  bag  as  an 
aneurysmal  sac  can  make  its  way  through  solid  bone  is  only  explained 
by  the  pressure  which  it  occasions  being  continuous  rather  than  inter- 
mittent, because  constant  pressure,  no  matter  how  soft  the  agent  pro- 
ducing it  is,  invariably  leads  to  the  removal  by  absorption  of  anything 
against  which  it  presses,  and  which  explains  how  the  soft  aneurysmal 


268     ■  CLINICAL  MEDICINE 

sacs  have  no  difficulty  in  making  their  way  through  some  of  the  most 
sohd  bones  of  the  body.  This  is  only  another  illustration  of  the  effect- 
iveness of  constant  perseverance. 

Other  forms  of  aneurysms  are  the  results  of  accidents  in  the 
progress  of  aneurysmal  sacs:  (i)  One  kind  is  called  arteriovenous 
aneurysm,  caused  by  a  communication  estabhshed  between  an  artery 
and  a  vein.  When  this  communication  is  direct,  the  chief  change 
is  in  the  vein,  which  is  dilated,  tortuous,  and  pulsating,  so  that  it  is 
termed  an  aneurysmal  varix.  These  aneurysms  are  often  the  result 
of  a  stab  or  similar  trauma,  in  which  the  injury  to  the  artery  and 
vein  occurs  simultaneously. 

(2)  Another  form  is  the  false  aneurysm  which  is  due  to  a  rupture  of 
all  three  coats,  and  the  blood  is  free  or  circumscribed  in  the  tissues. 

(3)  An  occasional  form  of  aneurysm  is  caused  when  an  embolus  has 
lodged  in  an  artery  and  permanently  plugged  it;  then  aneurysmal  dila- 
tation occurs  above  the  embolus. 

(4)  Lastly,  a  form  occurs  as  a  result  of  maUgnant  endocarditis,, 
when  the  blood  becomes  charged  with  micro-organisms;  these,  lodg- 
ing at  parts  already  weakened  by  various  causes,  set  up  ulcerative 
processes  which  may  result  in  multiple  aneurysms,  some  of  which  may 
be  large  and  saccular.   These  are  technically  called  microtic  aneurysms. 

Symptoms. — Aneurysms  in  the  thorax  may  give  rise  to  symptoms 
either  by  their  direct  pressure  or  by  putting  parts  on  the  stretch. 

Thus,  in  aneurysms  of  the  ascending  arch  of  the  aorta  the  sac  may 
compress  the  superior  vena  cava,  causing  engorgement  of  the  vessels 
of  the  head  and  right  arm,  particularly  if  it  presses  on  the  right  sub- 
clavian vein. 

In  aneurysm  of  the  transverse  arch,  even  though  small,  when  they 
grow  backward  they  may  press  upon  the  trachea  and  occasion  a 
paroxysmal  cough,  or  if  pressing  on  the  esophagus  cause  dysphagia. 
Thus,  a  small  aneurysm  from  the  lower  wall  of  the  arch  may  com- 
press a  bronchus,  producing  prolonged  bronchitis,  then  bronchiectasis, 
and  finally,  suppuration  in  the  lung,  with  death. 

Aneurysm  of  the  descending  arch  may  also  grow  backward  and 
erode  the  vertebra,  causing  great  pain,  sometimes  compressing  the 
spinal  cord  itself;  or  press  the  esophagus,  with  resulting  difficulty  in 
swallowing,  or  press  upon  a  main  bronchus,  with  effects  already  de- 
scribed. Aneurysms  of  the  descending  aorta  may  also  cause  all  these 
s3nnptoms,  though,  as  they  He  close  to  the  diaphragm,  they  may  not  be 
detected  until  pressure  signs  of  the  lungs,  with  pain  in  the  back  and 
dysphagia,  lead  to  inspection  and  palpation  of  the  back. 


ANEURYSM  269 

Symptoms  caused  by  the  stretching  produced  by  aneurysms  occur 
most  frequently  when  the  recurrent  laryngeal  nerves  are  involved. 
Thus,  the  inferior  or  recurrent  laryngeal,  so  called  from  its  reflected 
course,  is  the  motor  nerve  of  the  larynx.  It  rises  on  the  right  side  in 
front  of  the  subclavian  artery,  and  winds  from  before  backward  around 
that  vessel;  on  the  left  side  it  rises  in  front  of  the  arch  of  the  aorta,  and 
winds  from  before  backward  round  the  aorta,  at  the  point  where 
the  obliterated  remains  of  the  ductus  arteriosus  are  connected  with  it. 
This  illustrates  why  these  tortuous  nerves  supplying  the  larynx  so 
frequently  become  stretched  by  the  growth  of  thoracic  aneurysms,  with 
the  result  of  greatly  affecting  the  voice  or  aboUshing  it,  and  frequently 
causing  a  cough  strongly  resembhng  croup.  Inspection  of  the  larynx 
by  the  laryngoscope  may  show  complete  paralysis  of  the  vocal  chords 
or  of  only  one  chord,  sometimes  constituting  the  first  sign  of  a  thoracic 
aneurysm.  It  sometimes  happens  that  even  large  aneurysms  occur  in 
the  thorax  without  giving  rise  to  scarcely  any  symptoms,  and  maybe 
found  only  at  necropsy.  This  is  due  to  the  fact  that  the  organs  in  the 
chest  may  sometimes  be  freely  movable  or  else  only  partially  attached. 
As  the  growth  of  an  aneurysm  is  usually  gradual,  time  is  given  to  the 
parts  to  become  accustomed  to  their  displacement,  which  thus  may 
occur  without  an  appreciable  symptom.  Hence  we  read  of  aneurysms 
with  symptoms  and  aneurysms  without  symptoms,  facts  which  indicate 
with  what  care  the  chest  should  be  examined  in  such  cases. 

We  begin,  therefore,  with  inspection.  For  this  purpose  a  good  light 
is  essential.  Not  uncommonly  our  suspicions  may  be  aroused  by  a 
locaKzed  flush  on  the  cheek  of  one  side;  the  conjunctivas  may  be  in- 
jected; but  especial  notice  should  be  taken  of  the  veins,  both  on  the 
chest  and  on  the  arm.  It  is  very  suspicious  to  find  one  pupil  en- 
larged. We  may  now  carefully  look  for  any  sign  of  pulsation  in  the 
upper  region  of  the  chest.  Thus,  we  may  have  pulsation  that  is  due 
simply  to  dislocation  of  the  heart,  or  to  retraction  of  the  lung.  Aneu- 
rysmal pulsation  is  usually  above  the  level  of  the  third  rib,  and  most 
commonly  to  the  right  of  the  sternum,  either  in  the  first  or  second  inter- 
space. Instead  of  localized  pulsation,  there  may  be  only  a  uniform 
heaving  impulse,  which  may  be  noticeable  only  when  the  chest  is 
looked  at  obHquely  in  a  favorable  light.  Posteriorly,  when  pulsation 
occurs,  it  is  most  commonly  found  to  the  left  of  the  spine.  This  is 
a  most  valuable  sign  and  can  be  detected  if  the  patient  is  stripped 
and  bends  forward.  On  the  anterior  surface  of  the  chest  we  may  have 
in  the  upper  part  a  pulsating  tumor,  which  should  not  be  confounded 
with  a  pulsating  empyema,  for  these  are  always  down  and  on  the  side. 


270  CLINICAL  MEDICINE 

Following  inspection  is  palpation.  When  the  aneurysm  is  deep 
seated  and  not  apparent  externally,  the  bimanual  method  should  be 
used,  one  hand  upon  the  spine  and  the  other  on  the  sternum.  "There 
may  be  only  a  diffuse  impulse.  When  the  sac  has  perforated  the 
chest  wall  the  impulse  is,  as  a  rule,  forcible,  slow,  heaving,  and  expan- 
sile, and  has  the  same  quality  as  a  forcible  apex-beat.  The  sense  of 
resistance  may  be  very  great  if  there  are  thick  laminae  beneath  the 
skin;  more  rarely  the  sac  is  soft  and  fluctuating"  (Osier).  As 
Dickinson  has  pointed  out,  when  there  is  a  general  heaving  instead 
of  any  locaHzed  pulsation,  this  heaving  is  more  noticeable  when  the 
physician's  head  is  applied  to  the  part,  for  the  consequent  movement 
of  his  head  may  be  even  evident  to  a  bystander.  A  valuable  sign 
is  that  when  the  hand  is  applied  in  the  neighborhood  of  the  sac  a  dis- 
tinct diastolic  shock  may  be  felt.  Occasionally,  particularly  in  dila- 
tation of  the  arch,  a  systoHc  thrill  may  be  felt.  At  this  stage  of  the 
examination  the  nature  of  the  pulse  should  be  noticed,  both  radials 
being  examined  at  the  same  time,  because  a  pulse  in  one  radial  may 
be  quite  different  from  the  pulse  in  its  fellow.  This  fact  may  be  of 
decisive  significance. 

^^ Percussion. — The  small  and  deep-seated  aneurysms  are  in  this 
respect  negative.  In  the  larger  tumors,  as  soon  as  the  sac  reaches  the 
chest  wall,  there  is  produced  an  area  of  abnormal  dulness,  the  position 
of  which  depends  upon  the  part  of  the  aorta  affected.  Aneurysms  of 
the  ascending  arch  grow  forward  and  to  the  right,  producing  dulness  on 
one  side  of  the  manubrium;  those  from  the  transverse  arch  produce 
dulness  in  the  middle  line,  extending  toward  the  left  of  the  sternum, 
while  aneurysms  of  the  descending  portion  most  commonly  produce 
dulness  in  the  left  interscapular  and  scapular  regions.  The  percussion 
note  is  flat  and  gives  a  feehng  of  increased  resistance. 

^^Auscultation. — ^Adventitious  sounds  are  not  always  to  be  heard. 
Even  in  a  large  sac  there  may  be  no  murmur.  Much  depends  upon  the 
thickness  of  the  laminae  of  fibrin.  An  important  sign,  particularly  if 
heard  over  a  dull  region,  is  a  ringing,  accentuated  second  sound,  a 
phenomenon  rarely  missed  in  large  aneurysms  of  the  aortic  arch" 
(Osier). 

In  former  times  much  stress  was  laid  upon  aneurysmal  bruit, 
but  these  are  by  no  means  constant  and  not  especially  diagnostic  when 
taken  by  themselves. 

A  valuable  sign,  which  ought  to  be  called  OKver's  sign,  is  that  of 
tracheal  tugging,  present  in  deep-seated  aneurysms,  who  thus  describes 
how  to  eHcit  it:  'Tlace  the  patient  in  the  erect  position,  and  direct 


ANEURYSM  27 I 

him  to  close  his  mouth  and  elevate  his  chin  to  almost  the  full  extent; 
then  grasp  the  cricoid  cartilage  between  the  finger  and  thumb,  and  thus 
make  steady  and  gentle  upward  pressure  upon  it,  when,  if  dilatation  in 
aneurysm  exists,  the  pulsation  of  the  aorta  will  be  distinctly  felt  trans- 
mitted through  the  trachea  to  the  hand."  On  the  other  hand,  marked 
diminution  in  the  breath-sounds  on  the  one  side  are  good  indications  of 
pressure  on  the  lung  substance  by  an  aneurysm. 

Of  the  symptoms,  we  may  say  that  the  commonest  and  most  sig- 
nificant is  pain,  but  cases  occur  in  which  pain  is  never  complained  of; 
when,  however,  the  aneurysm  erodes  vertebrae  the  pain  may  be  dread- 
ful; its  characters  then  are  that  it  is  localized,  and  if  in  the  back  the 
patients  usually  indicate  its  location  by  the  thumb.  Besides  being  con- 
stant there  may  be  paroxysms  of  a  lancinating  character.  Sometimes 
they  are  severe,  when  aneurysm  is  pressing  and  eroding  the  ribs,  and 
then  we  hsten  over  the  sac  protruding  between  the  bones.  When  the 
aneurysms  involve  the  aortic  ring,  as  we  have  described,  true  anginal 
attacks  occur  resembling  angina  pectoris,  radiating  down  the  left  arm 
and  up  the  side  of  the  neck. 

Dyspnea,  quite  apart  from  that  caused  by  laryngeal  spasm,  may 
occur  from  pressure  from  the  trachea  or  the  main  bronchus,  the  symp- 
toms of  which  we  have  already  described.  In  such  cases  the  breath- 
ing is  often  loud  with  a  stridor. 

Hemorrhage,  however,  is  always  of  serious  import,  although  it  may 
occur  as  a  sort  of  mere  leakage  from  the  mucous  membrane  of  the 
trachea  where  it  is  pressed  by  the  aneurysm.  Yet  more  commonly 
it  is  the  fatal  result  of  ulceration  of  the  sac  into  the  lung  or  into  the 
air-passages. 

We  need  not  discuss  other  aneurysms,  which  may  occur  in  different 
parts  of  the  body,  such  as  popliteal  aneurysms,  because  they  are  usually 
more  of  surgical  than  of  medical  interest.  A  word,  however,  is  not 
out  of  place  about  a  symptom  frequently  occurring  in  the  course  of  the 
abdominal  aorta,  namely,  throbbing.  Compared  with  thoracic  aneu- 
rysms, abdominal  aneurysms  are  uncommon,  but  pronounced  throbbing 
of  the  abdominal  aorta,  which  may  be  easily  mistaken  for  that  of 
aneurysm,  is  not  unusual  in  cases  of  neurasthenia  and  hysteria  or  some- 
times in  conditions  of  simple  anemia.  These  may  be  very  deceptive, 
because,  on  pressing  the  stethoscope  deeply  down,  an  actual  bruit  may 
be  heard;  it  is  otherwise  if  the  patient  complains  of  a  fixed  localized 
pain  in  the  back.  I  had  a  patient  who  continued  to  complain  of  such 
a  pain,  always  referred  to  the  same  spot,  and,  though  he  looked  quite 
healthy,  yet  admitted  that  he  had  contracted  syphilis  twenty-two 


272 


CLINICAL  MEDICINE 


years  before;  in  time  the  case  became  clear  by  the  erosion  of  the  ver- 
tebree,  with  symptoms  of  paraplegia.  Throbbing  of  the  mesenteric 
artery  is  also  common  in  inflammatory  cohtis  of  dysentery,  but  rarely 
gives  rise  to  any  suspicion  of  aneurysm. 

ENDOCARDITIS 

As  auscultation  furnishes  the  chief  means  for  estimating  the  con- 
ditions of  the  heart,  so  the  student  should  recognize  the  many  differ- 
ences between  pulmonary  and  cardiac  auscultation.  Thus,  as  to  area, 
the  heart  being  a  single  organ,  occupies  but  a  fraction  of  the  space 
taken  by  the  double  apparatus  of  breathing.  Much  more  than  this, 
however,  is  the  frequency  of  the  sounds.  I  had  a  patient  whose  acts 
of  breathing  were  thirty  in  the  minute,  or  double  that  number  of 
inspirations  and  expirations,  but  meantime  he  had  with  a  pulse  of  140 
double  murmurs  at  the  aortic  and  at  the  mitral  valves,  besides  the  to- 
and-fro  murmurs  produced  by  pericarditis.  He  had,  therefore,  at 
least  720  sounds  generated  by  his  heart  every  minute.  This  fact 
alone  shows  how  much  more  difficult  physical  examination  of  the  heart 
is  than  that  of  any  other  organ,  and  the  student  should  follow  these 
simple  rules:  First,  begin  with  the  easiest  thing  to  determine,  namely, 
where  the  sound  is  heard  plainest  or  loudest.  This  initial  step  should 
be  very  carefully  settled.  Second,  in  what  direction  the  murmur 
transmits,  or  equally  so,  where  it  does  not  transmit;  and,  lastly,  the 
most  difficult  of  all,  with  what  action  of  the  heart  it  coincides. 

As  the  conclusions  from  auscultation  are  thus  so  often  uncertain, 
every  other  measure  that  may  further  aid  in  diagnosis  should  be  re- 
sorted to,  and  among  them  are  alterations  in  the  normal  sounds  of 
the  heart.  Thus,  accentuation  of  the  second  sound  is  of  much  sig- 
nificance in  arteriosclerosis,  and  Hkewise  in  the  pulmonary  valves  in 
the  case  of  mitral  stenosis.  Palpation,  also,  is  of  great  service  for  esti- 
mating the  strength  of  the  heart-beat.  If  this  be  strong  and  heaving 
on  the  left  side,  it  indicates  that  the  walls  of  the  ventricle  are  sound. 
If  the  heart's  impulse,  besides  being  strong,  occupies  an  extended  area 
of  the  chest  wall,  it  indicates  hypertrophy.  If,  on  the  other  hand,  the 
impulse  be  feeble  or  absent,  it  shows  weakness  of  the  myocardium.  If, 
again,  the  impulse  be  weak,  but  also  diffused,  it  indicates  the  presence 
of  dilatation.  An  important  sign  brought  out  by  palpation  is  the  pres- 
ence of  a  thrill,  which  if  felt  in  its  proper  place  is  almost  pathognomonic 
of  mitral  stenosis.  Percussion  is  of  value  in  estimating  the  degree  of 
the  presence  or  absence  of  effusion  into  the  pericardium,  or  of  dilata- 
tion of  the  heart  cavities.     Meantime  inspection  is  of  great  service 


ENDOCARDITIS  273 

in  locating  the  apex-beat  of  the  heart,  or,  in  other  cases,  especially 
in  children,  of  bulging,  due  either  to  hypertrophy  or  to  effusion. 

Diseases  of  the  heart  are  either  primary  or  secondary:  primary, 
when  they  originate  in  the  heart  itself  or  in  its  appendages;  secondary, 
when  the  heart  is  deranged  by  conditions  of  the  general  circulation, 
notably  by  obstruction  in  the  arteries,  as  that  which  occurs  in  arterio- 
sclerosis. Of  the  primary  affections  of  the  heart,  we  begin  with  acute 
simple  endocarditis.  This  is  invariably  due  to  an  infection  of  some 
kind,  the  seriousness  of  which  is  according  to  the  particular  infecting 
organism.  The  commonest  of  these  is  by  the  Diplococcus  rheumati- 
cus  of  Wassermann  and  Poynton.  This  form  of  endocarditis  is  esti- 
mated by  different  writers  to  be  between  20  and  30  per  cent.  These 
figures,  however,  are  inaccurate  unless  special  pains  be  taken  to  note 
the  statistics  at  different  ages.  Thus,  endocarditis  from  rheumatism 
occurs  much  more  frequently  in  children  than  in  adults,  rheumatic 
endocarditis  being  estimated  in  children  at  61  per  cent,  by  West,  and 
80  per  cent,  by  Grassicourt.  This  form  of  endocarditis  is  spoken  of 
as  the  benign  form,  but  it  is  only  so  in  comparison  with  the  mahgnant 
endocarditis,  for  no  form  of  cardiac  inflammation  is  really  ever  benign; 
the  patients  may  recover  in  a  few  weeks,  so  that  they  mistakenly 
leave  their  beds.  But  the  damage  done  to  the  cardiac  valves  and 
structures  by  rheumatic  inflammation  is  often  progressive  and  per- 
manent, the  changes  in  the  valves  resulting  in  such  puckering  of  those 
structures  that  in  time  they  either  become  incompetent,  so  as  to  pro- 
duce regurgitation,  or  narrowed  by  stenotic  changes,  and  then  become 
equally  serious  obstructions.  In  most  cases  of  stenosis  of  the  mitral 
valve  there  is  also  incompetence  with  regurgitation,  as  will  be  noted 
further  on.  Endocarditis  commonly  begins  as  a  simple  valvulitis, 
and  it  is  important  to  note  why  a  rheumatic  valvulitis  is  so  much  more 
serious  than  a  rheumatic  inflammation  an3rwhere  else. 

Thus,  an  acute  rheumatic  arthritis  is  accompanied  by  much  pain 
and  swelhng,  with  effusion  into  the  joint,  but  this  may,  within  twenty- 
four  hours,  be  shifted  to  another  joint,  whereupon  the  effects  of  the 
inflammation  in  the  original  joint  may  quite  disappear.  But  rheu- 
matic valvuHtis,  on  the  contrary,  is  no  transient  matter,  owing  to  the 
incessant  movement  of  the  valves.  Were  an  inflamed  joint,  instead 
of  being  kept  quite  rigidly  quiet,  as  is  usually  the  case,  moved  back  and 
forth  more  than  100  times  a  minute,  the  inflammation  would  produce 
serious  structural  changes,  notwithstanding  its  rheumatic  character. 

The  cardiac  valves  are  covered  by  a  deHcate  endothehum  which 
serves  the  same  protective  office  as  the  epitheUal  lining  of  mucous 

18 


274  .  CLINICAL  MEDICINE 

membrane.  Therefore,  when  this  valvular  endothelium  is  damaged 
and  the  subjacent  tissue  thus  exposed,  there  follows  as  a  result  the 
precipitation  of  fibrin  and  of  blood-platelets  upon  it.  Later  this 
deposit  becomes  invaded  by  various  micro-organisms,  such  as  strepto- 
cocci, staphylococci,  pneumococci,  or  gonococci,  according  to  the  nature 
of  the  case. 

Every  attack  of  rheumatic  valvulitis,  therefore,  leaves  its  trace 
upon  the  affected  structure,  and  as  these  rheumatic  inflammations 
are  very  prone  to  recur,  the  valves  become  progressively  altered  in 
shape  and  in  texture,  with  a  further  tendency  of  involvement  of  sub- 
sidiary tissues,  such  as  the  chordae  tendinae  and  the  papillary  muscles. 
The  chordae  tendinae  may  become  shortened  and  encrusted  with  de- 
posits, notably  of  lime  salts.  These  changes  in  time  may  not  only 
render  the  valves  incompetent  to  close  perfectly,  but  also  to  adhere 
together,  and  thus  constitute  both  an  obstruction  to  the  flow  of  blood 
from  stenosis  and,  equally,  regurgitation,  through  valvular  incompe- 
tence. Lastly,  the  entire  ring  of  the  orifice  may  be  transformed  into 
a  tissue  of  cartilaginous  hardness,  with  such  extensive  deposits  of  Ume 
salts  as  to  justify  the  old  term  of  "ossification  of  the  heart." 

The  first  attack  of  rheumatic  fever  is  also  more  often  followed  by 
endocarditis  than  subsequent  attacks,  while  in  children  the  signs  of 
arthritis  may  be  very  slight.  To  this  also  should  be  added  that 
children  are  especially  liable  to  chorea,  which  is  a  rheumatic  affection, 
and  as  often  accompanied  by  endocarditis  as  rheumatic  fever  itself. 
The  endocarditis  dependent  upon  rheumatic  fever  most  frequently 
attacks  the  mitral  valve;  much  less  frequently,  the  aortic  valve.  In  a 
ratio  among  535  cases  reported  in  St.  Thomas'  Hospital,  the  mitral 
was  attacked  in  87  per  cent,  and  the  aortic  in  12  per  cent.  On  the 
mitral  valve  the  auricular  surface  is  affected,  while  in  the  aortic  valve 
it  is  the  ventricular  surface.  In  general,  the  valves  of  the  left  side  are 
affected  twenty  times  as  often  as  those  of  the  right. 

Endocarditis  may  occur  as  early  as  the  end  of  the  first  week  of 
rheumatic  fever,  though  in  most  cases  not  until  the  end  of  the  second 
week,  but  it  should  be  remembered  from  what  we  have  already  stated 
that  tonsillitis  may  be  the  only  antecedent  of  endocarditis,  as  it 
sometimes  is  of  pericarditis. 

Rheumatic  fever,  as  we  have  remarked,  is  a  disease  of  early  life, 
and  is  progressively  less  frequent  as  a  first  attack  after  twenty-five 
years  of  age.  Later  in  life  endocarditis  may  follow  intestinal  ulcera- 
tion, or  the  infection  may  proceed  from  the  genito-utinary  tract,  such 
as  from  pyelitis,  cystitis,  or  pelvic  infections  in  women,  and  prostatic 


ENDOCARDITIS  275 

infections  in  men.  Scarlet  fever  may  also  produce  endocarditis  just 
as  it  causes  arthritis.  In  other  infections,  such  as  measles  or  diphtheria 
and  influenza,  endocarditis  is  uncommon,  although  in  the  latter, 
namely,  influenza  and  diphtheria,  myocarditis  is  frequent. 

It  is  doubtful  if  endocarditis,  especially  if  severe,  ever  occurs 
without  causing  at  the  same  time  myocarditis,  with  resulting  weakness 
and  consequent  dilatation  of  the  heart  walls.  This  should  be  borne 
in  mind  in  the  endocarditis  of  children,  when  temporary  dilatation  of 
the  heart  in  rheumatic  fever  may  occasion  very  serious  symptoms, 
such  as  dyspnea  and  cyanosis. 

The  fibrin  which  is  deposited  upon  the  valves  usually  ends  in  the 
formation  of  warty  growths  which  may  be  of  different  sizes  and  shapes. 
Sometimes  they  are  pedunculated,  with  but  slender  attachments,  so 
that  they  are  broken  off  and  carried  elsewhere  in  the  blood-current  as 
emboli.  In  other  cases  they  are  firmly  attached,  and  may  grow  into 
extensive  granulations.  Usually  they  are  not  attached  at  the  free 
end  of  the  valve,  but  somewhat  within  it.  Their  presence  is  not  such 
a  frequent  cause  of  valvular  murmurs  as  are  other  changes  in  the  shape 
of  the  valves,  which  we  have  described. 

Treatment  of  Simple  Endocarditis. — As  endocarditis  should  never 
be  called  benign,  though  it  be  of  a  simple  rheumatic  variety,  so  the 
question  of  prophylaxis  is  as  important  as  any  other  in  the  management 
of  these  cases.  Considering  how  often  rheumatic  fever  is  initiated  by 
an  infection  of  the  tonsils,  repeated  washing  of  the  throat  after  the 
fashion  already  described  in  the  treatment  of  scarlatina  and  of  diph- 
theria should  be  perseveringly  followed  from  the  first  onset  of  rheu- 
matic sjnnptoms.  I  have  thus  often  cut  short  a  rheumatic  infection 
in  patients  who  were  supposed  to  show  a  constitutional  tendency  to 
rheumatism.  Another  important  measure  is  to  insure  perfect  bodily 
and  mental  rest  by  directing  the  patient  to  remain  in  bed  for  weeks  at 
a  time.  This  necessary  precaution  is  often  difficult  to  find  observed 
by  the  patient,  but  many  a  case  of  hopeless  valvular  change  may 
be  ascribed  to  the  impatience  of  the  patients  from  the  irksome  observ- 
ance of  the  directions  of  the  physician,  especially  by  children.  The 
old  prescription  of  six  weeks  in  bed  for  an  attack  of  rheumatic  fever 
has  everything  to  recommend  it,  though  in  many  cases  six  weeks  is 
not  long  enough.  Another  cause  of  unmanageable  endocarditis  is 
the  modern  reliance  upon  the  salicylates  in  the  treatment  of  rheumatic 
fever.  The  salicylates  have  no  power  either  to  prevent  or  to  modify 
the  endocarditis.  All  that  they  do  is  to  reduce  the  arthritic  pain  and 
the  accompanying  fever,  while  the  endocarditis  proceeds  unchecked. 


276  CLINICAL  MEDICINE 

Quite  different  in  my  experience  is  the  effect  of  the  resort  to  alkalis, 
originally  advocated  by  Dr.  Fuller,  of  London  Hospital,  who  maintained 
that  no  case  of  endocarditis  need  occur  in  rheumatic  fever  if  his  direc- 
tions were  followed.  Instead  of  his  complicated  prescription,  the  same 
results  may  be  secured  by  administering  from  i  to  2  drams  of  the 
bicarbonate  of  potash,  with  a  scruple  of  the  citrate  of  potash,  every 
two  or  three  hours,  until  the  urine  becomes  alkaline,  when  the  doses 
might  be  given  at  longer  intervals,  to  be  resumed,  however,  so  soon 
as  the  urine  becomes  acid.  Meantime,  the  tincture  of  aconite  is  in- 
valuable in  such  cases  for  soothing  the  excited  heart.  It  should  be 
given  in  doses  regulated  according  to  age,  in  order  to  secure  slowing  of 
the  pulse  and  relief  of  the  accompanjdng  pain.  Remarks  on  the 
treatment  of  rheumatic  fever  are  also  applicable  here,  because,  owing 
to  the  accompanying  perspiration,  not  only  should  the  chest  be  care- 
fully protected,  but,  if  a  child,  the  body  should  be  enclosed  in  a  canton 
flannel  bag,  as  heretofore  mentioned. 

Malignant  Endocarditis 

While  endocarditis  is  always  due  to  an  infection,  we  may  not  be 
sure  what  the  special  infection  is.  Cases  which  begin  with  all  the  char- 
acteristics of  a  rheumatic  endocarditis  may  have  a  separate  infection 
engrafted  upon  the  original  disease,  with  very  uncertain  signs  of  the 
change.  Thus,  I  had  a  hospital  patient  whom  I  was  told  was  suffer- 
ing from  severe  malaria,  as  she  had  pronounced  rigors  occurring  regu- 
larly at  four  o'clock  in  the  afternoon,  followed  by  high  fever,  ending 
in  profuse  sweating.  Examination  of  her  heart  showed  no  symptoms 
of  valvulitis,  the  sounds  being  normal  in  quality  and  in  rhythm. 
From  the  aspect  of  the  patient  and  the  gravity  of  the  constitutional 
symptoms,  I  said  that  the  case  could  not  possibly  be  mere  ague.  The 
patient  died  the  next  day  during  one  of  the  paroxysms,  and  at  post- 
mortem a  clean-cut,  infecting  ulcer  was  found  on  the  septum,  which 
in  no  way  involved  either  the  mitral  or  aortic  valve.  In  short,  she 
died  of  what  is  very  properly  termed  malignant  endocarditis.  This 
case  illustrates  the  frequent  difficulty  of  diagnosis  in  this  grave  com- 
plaint. The  nature  of  her  ailment  would  have  been  revealed  by  an 
examination  of  her  blood,  which  was  unfortunately  omitted,  for  ulcera- 
tive endocarditis  is  accompanied  by  a  high  degree  of  leukocytosis, 
while  malarial  affections  are  characterized  by  a  low  count  of  leuko- 
cytes in  the  blood.  If  we  rely  upon  the  cardiac  symptoms  only,  in- 
stead of  the  Diplococcus  rheumaticus,  the  infecting  organisms  may  be 
the  pneumococcus,  the  gonococcus,  or  any  one  of  the  pyogenic  organ- 


MALIGNANT    ENDOCARDITIS  277 

isms,  the  Staphylococcus  pyogenes  aureus  being,  on  the  whole,  the 
most  common. 

Mahgnant  endocarditis  may  occur  at  any  time  in  the  course  of 
rheumatic  fever,  with  only  an  exacerbation  of  the  original  symptoms 
being  present.  In  the  majority  of  cases,  however,  there  recurs  an 
irregular  pyrexia,  which  of  itself  is  a  suspicious  symptom.  When 
to  this  is  added  unmistakable  signs  of  emboli,  causing  small  ecchy- 
motic  spots  on  the  surface,  notably  in  the  palms  of  the  hands,  or  pain 
in  the  side  and  local  peritonitis  from  infarction  of  the  spleen,  bloody 
urine  from  implication  of  the  kidneys,  or  impaired  vision  from  retinal 
hemorrhage,  the  diagnosis  is  no  longer  doubtful,  but  these  derange- 
ments may  also  be  accompanied  by  delirium,  coma,  or  paralysis  from 
involvement  of  the  brain  or  its  membranes. 

In  many  cases,  if  not  in  most,  the  process  starts  from  an  old  focus 
of  valvular  disease,  and  may  then  be  extremely  irregular  in  its  course. 
I  had  a  patient  who  had  long  suffered  from  chronic  disease  of  his 
pulmonary  valves,  probably  congenital;  he  continued  to  have  irreg- 
ular attacks  of  fever  for  two  years  before  the  terminal  symptoms  set 
in.  Another  patient,  past  middle  life,  who  had  old  valvular  disease, 
died  at  last  with  symptoms  suggesting  a  distribution  of  emboli,  com- 
ing, as  it  were,  like  a  spray  from  his  aortic  valves,  for  he  became  so 
covered  with  ecchymoses  of  his  whole  skin  that  little  remained  of  its 
natural  color.  Some  of  these  cases  present  all  the  symptoms  of  a 
severe  septicemia,  and  the  infecting  organisms  may  be  isolated  from 
the  blood. 

Another  and  more  common  class  is  characterized  by  t3q3hoid 
symptoms,  or  a  low  fever,  early  prostration,  delirium  and  coma,  with 
profuse  sweating.  In  these  patients  the  cardiac  symptoms  may  be  so 
massed  by  the  systemic  conditions  that  only  on  the  appearance  of 
ecchymotic  spots  does  the  true  diagnosis  become  estabhshed.  These 
cases  might  easily  be  mistaken  for  the  cerebrospinal  fever,  which  goes 
by  the  name  of  spotted  fever. 

The  most  difficult  forms  to  recognize  are  those  uncommon  cases 
termed  "chronic  infective  endocarditis,"  in  which,  at  first,  fever  is  the 
only  symptom.  These  patients  may  keep  at  work  for  months  with 
nothing  but  a  daily  rise  of  fever,  along  with  progressive  weakness  and 
anemia.  EmboHc  features  in  them  are  not  common,  and  they  die 
from  simple  exhaustion,  to  reveal  postmortem  very  extensive  vegeta- 
tive endocarditis,  with  large,  irregular,  but  firm  vegetations,  which 
do  not  break  away  and  thus  form  emboli. 

Treatment. — We  have  no  treatment  for  malignant  endocarditis. 


278  CLINICAL  MEDICINE 

If  patients  supposed  to  have  the  disease  recover,  the  inference  is  that 
the  diagnosis  was  mistaken,  and  that  they  had  simple  endocarditis 
instead.  Some  have  hoped  that  autogenetic  vaccine  cultivated 
from  organisms  present  in  the  blood  might  be  curative,  but  so  far  no 
trustworthy  accounts  of  success  by  such  vaccines  have  been  reported. 
When  the  endocarditis  has  been  produced  by  the  gonococcus,  the  out- 
look is  absolutely  hopeless,  however  easy  it  be  to  cultivate  a  gono- 
coccus vaccine  from  the  blood. 

It  is  noteworthy  how  often  the  history  of  malignant  endocarditis 
is  dated,  by  the  patients  themselves,  from  bathing  in  cold  water. 
The  first  case  of  this  affection  in  my  own  practice  was  that  of  a  young 
boy,  who  could  trace  the  beginning  of  his  trouble  to  a  single  cold  bath. 
I  also  had  a  young  lady  who  remained  in  a  cold  sea-bath  so  long  that 
she  could  not  get  up  any  reaction  after  it,  and  the  first  sign  of  her  fatal 
illness  was  the  appearance  of  the  characteristic  ecchymotic  spots  in 
the  palms  of  her  hands. 

PERICARDITIS 

The  recognition  of  this  common  complaint  may  be  easy,  particu- 
larly in  its  first  stages,  or,  on  the  other  hand,  so  difficult  that  its  pres- 
ence during  life  will  often  be  revealed  only  at  autopsy.  There  is  no 
serious  disease,  indeed,  whose  occurrence  is  so  often  unsuspected  as 
pericarditis.  By  far  its  most  common  cause  in  early  life  is  rheumatic 
fever,  and  on  that  account  it  should  be  looked  for  in  chorea,  or  it  is 
often  associated  with  that  common  precursor  of  rheumatism,  tonsil- 
litis. Pericarditis  may  occur  so  early  in  such  cases  as  to  precede  any 
symptoms  of  arthritis.  On  the  other  hand,  the  pericardium  is  at- 
tacked in  tuberculosis,  and  hkewise  in  later  life  it  may  complicate 
nephritis  or  even  gout.  It  is  common  also  in  other  septicemic  infec- 
tions, such  as  puerperal  fever,  ulcerative  endocarditis,  and  general 
septicemic  conditions  produced  by  pyogenic  cocci.  In  fact,  it  may 
occur  as  a  terminal  infection  in  any  chronic  constitutional  disease. 

The  occurrence  of  pericarditis  in  rheumatic  fever  is  variously  rated 
by  different  writers,  some  putting  it  as  low  as  6  per  cent.,  and  others 
at  30  per  cent.,  the  higher  figures  being  the  more  probable.  Though 
all  inflammations  of  serous  membranes  lead  to  serious  sequelae  from 
adhesions  between  the  two  surfaces  of  the  membrane,  yet  in  rheumatic 
inflammations  of  the  pericardium  these  may  not  at  first  excite  sus- 
picion, and  are  only  found  out  by  the  presence,  over  the  right  ventricle, 
of  its  to-and-fro  sound.  Meantime  the  endocardial  or  valvular  sounds 
are  quite  distinct.     When,  however,  a  large  effusion  has  taken  place 


PERICARDITIS  279 

into  the  pericardial  sac,  the  endocardial  sounds  may  become  very  much 
muffled,  so  as  not  to  be  readily  detected.  This  weakening  of  the  en- 
docardial sound  is  a  valuable  sign  of  pericardial  effusion.  The  friction 
sounds  of  pericarditis  are  readily  detected  because  they  seem  to  be 
superficial  and  near  the  ear,  and  on  that  account  are  better  appre- 
ciated by  the  ear  itself  than  by  the  stethoscope.  When,  however, 
the  area  of  the  inflammation  is  hmited,  it  would  be  better  to  rely 
on  the  stethoscope.  Often  on  palpation  the  finger  may  detect  a  fre- 
mitus there.  Both  the  fremitus  and  the  friction  sound  will  soon  dis- 
appear when  effusion  in  the  pericardial  sac  occurs,  though  they  may 
remain  for  some  time  at  the  base  of  the  heart  and  at  its  apex.  In 
such  cases  the  effusion  may  be  simply  dry ;  otherwise  it  is  serofibrinous, 
and  when  it  becomes  thick  the  two  surfaces  when  separated  may  pre- 
sent many  long  threads,  so  as  to  give  the  name,  among  old  writers, 
of  a  hairy  heart.  When  still  thicker,  the  effusion  becomes  honey- 
combed, much  as  if  the  surfaces  were  separated  by  butter.  Should 
the  exudation,  however,  be  more  fluid,  the  friction  sound  may  disappear 
while  the  endocardial  sounds  become  more  or  less  muffled.  If  the 
effusion  is  very  liquid,  it  may  accumulate  to  a  large  extent,  whereupon 
the  precordial  percussion  area  of  dulness  greatly  increases,  becoming 
somewhat  pear  shaped,  with  the  base  below,  and  ending  above  in  the 
shape  of  a  truncated  cone. 

There  is  no  affection  whose  signs  by  auscultation  are  so  variable 
as  in  pericarditis,  present  one  day  and  absent  another,  and  often 
altered  by  simple  changes  of  position,  such  as  leaning  forward.  These 
serofibrinous  exudations  are  often  absorbed  with  great  rapidity,  leav- 
ing in  time  the  two  surfaces  of  the  pericardium — the  visceral  and 
parietal — permanently  adherent,  and  yet  in  many  cases  with  but  few 
signs  of  the  change.  In  some  cases,  however,  from  the  very  beginning 
the  patients  complain  of  more  or  less  precordial  pains,  which  may 
have  to  be  relieved  by  opium.  Pericarditis  is  pretty  sure  to  be  accom- 
panied, if  at  ah  severe,  by  myocarditis,  and,  as  remarked  in  our  chap- 
ter upon  Rheumatic  Fever,  this  softening  of  the  heart  walls  easily  leads 
to  cardiac  dilatation.  It  is  often  surprising  in  the  rheumatic  cardiac 
inflammations  of  children  how  soon  serious  s3nTiptoms  accompanied 
by  severe  dyspnea  may  develop.  In  this  form  of  the  disease  the  exuda- 
tion, from  being  very  slight,  increases  in  amount,  but  nevertheless 
does  not  present  the  serious  aspect  which  occurs  if  the  exudation 
becomes  bloody  or  purulent.  In  some  cases  the  effusion  of  fluid  may 
become  so  great  as  to  endanger  life  from  embarrassment  of  the  heart. 
Although  the  fever  at  no  time  is  apt  to  be  high,  often  in  the  worst 


28o  CLINICAL   MEDICINE 

cases  not  exceeding  102°  or  103°  F.,  yet  the  dyspnea  is  distressing,  and 
the  patients  are  very  restless,  the  face  becomes  dusky,  the  pulse  is 
very  small,  and  we  may  have  the  pulsus  paradoxus,  in  which  the  pulse 
is  affected  by  the  movements  of  respiration.  DeHrium  may  then  set 
in,  often  of  a  peculiar  kind,  marked  by  obstinate  taciturnity;  at  other 
times,  noisy  muttering.  Should  the  exudation  be  very  large  in  amount, 
sometimes  from  i  to  2  liters  in  quantity,  the  ominous  symptom  of  dys- 
phagia makes  its  appearance.  The  left  lung  also  becomes  compressed 
at  its  base,  and  an  area  of  dulness  on  percussion  develops  posteriorly 
between  the  spine  of  the  scapula  and  the  vertebrae  (Ewart's  sign). 
Similarly,  there  is  an  absence  of  resonance  in  the  fifth  right  intercostal 
space,  called  Rotch's  sign.  In  children  there  may  be  an  actual  bulging 
produced  by  the  effusion  in  the  precordial  area.  The  most  important 
clinical  sign  then  is  dyspnea. 

Pericarditis  is  a  very  frequent  accompaniment  of  pneumonia,  pro- 
duced by  extension  of  the  pleuropneumonic  process  to  the  pericardium. 
It  is  largely  on  this  account  that  the  existence  of  pericarditis  is 
masked  by  the  sounds  proper  to  both  pneumonia  and  pleurisy,  such 
as  bronchial  breathing  and  pleuritic  friction.  Large  effusions  into  the 
pericardial  sac  have,  on  this  account,  been  overlooked  until  they  are 
revealed  at  autopsies. 

Treatment. — The  treatment  of  pericarditis  in  the  acute  stage  is 
usually  that  of  the  diseases  of  which  it  is  a  complication.  It  is  other- 
wise when  some  of  its  mechanical  effects  are  produced,  such  as  the 
embarrassment  of  the  heart  by  the  amount  of  effusion.  It  would 
be  well  to  begin  by  rubbing  the  precordium  with  blue  ointment  of 
mercury.  If  there  be  much  pain,  however,  this  may  be  preceded  by 
leeching,  which  sometimes  may  give  great  relief.  After  the  acute  in- 
flammation has  subsided,  large  blisters  often  produce  surprising  results 
in  causing  both  subsidence  of  pain 'and  dyspnea  and  absorption  of  the 
effusion.  If,  however,  the  mechanical  effects  of  the  effusion  are  very 
serious,  as  above  described,  aspiration  affords  the  best  relief,  both  in 
serous  effusions  and  when  there  is  blood  present  from  tuberculous  in- 
flammation. In  them  the  aspiration  may  be  repeated  as  often  as 
occasion  requires  by  the  symptoms.  The  needle  should  be  intro- 
duced upward  and  backward,  close  to  the  costal  margin  in  the  left 
costal  xiphoid  angle.  Should  the  effusion,  however,  be  purulent,  noth- 
ing short  of  incision  of  the  pericardium  and  drainage  will  answer  in 
these  serious  cases. 


BRADYCARDIA  28 I 


PERI-PERICARDITIS 


It  is  otherwise  with  the  chronic  result  of  extensive  pericardial 
adhesion  to  the  pleura  or  to  the  chest  wall.  In  these  cases  the 
movements  of  the  heart  become  very  much  embarrassed,  as  they 
prevent  its  systoHc  contraction,  thus  leading  to  extensive  dilatation, 
dropsy,  and  engorgement  of  the  Uver.  On  inspection,  the  extent 
of  the  cardiac  impulse  is  greatly  increased,  with  similar  excursions  of 
the  visible  impulse  beat,  which  may  extend  from  the  third  to  the  sixth 
interspace.  One  of  the  best  signs  of  this  condition  is  that  of  an  actual 
systolic  retraction  due  to  the  pull  of  the  adherent  heart  upon  the  lower 
movable  rib  spaces .  .  The  heart  may  be  so  dilated  in  these  conditions 
that  its  valves  become  incompetent,  often  leading  to  ascites.  I 
have  sometimes  produced  a  mitigation  of  these  symptoms  by  firmly 
strapping  the  lower  ribs  on  the  left  side,  applying  the  straps  from  the 
vertebrae  to  the  middle  Hne  anteriorly.  The  greatest  rehef,  however, 
is  secured  by  Brauer's  operation  of  cardiolysis,  5  or  6  cm.  of  the 
fourth,  fifth,  and  sixth  left  ribs  being  resected,  so  as  to  set  the  heart 
free  from  its  fibrous  entanglements.  This  operation  has  been  suc- 
cessful in  cases  that  otherwise  would  soon  have  succumbed. 

BRADYCARDIA 

Bradycardia,  or  slow  pulse,  is  sometimes  of  very  little  significance, 
for  I  have  known  it  to  occur  in  perfectly  healthy  persons  who  through- 
out life  may  have  a  pulse-rate  of  40.  Pathologically,  it  is  very  common 
in  jaundice  and  in  old  persons  with  thickened  arteries  and  myo- 
cardial changes.  It  should  be  noted  that  it  sometimes  occurs  in 
meningitis. 

In  all  cases  a  careful  comparison  should  be  made  between  the  pulse 
at  the  wrist  and  the  frequency  of  the  heart-beat,  for  the  pulse  at  the 
wrist  may  count  only  40,  while  the  heart-beat  is  80,  from  the  inability 
of  the  heart  to  propel  the  wave  so  far  as  the  wrist. 

Bradycardia  comes  on  in  aged  persons  with  widely  distributed 
changes  in  the  arteries  and  who  also  have  weak  hearts.  Such  patients 
frequently  have  epileptiform  attacks,  which  cause  them  to  fall  in  the 
street,  and.  with  temporary  fits  of  unconsciousness.  I  have  had 
cases,  however,  of  a  habitual  pulse  as  low  as  30  to  36,  with  frequent 
attacks  of  unconsciousness,  and  yet  without  any  detectable  abnor- 
mality either  in  their  arteries  or  in  their  heart  walls.  In  the  cases  just 
referred  to,  occurring  in  elderly  persons,  relief  may  be  very  prompt 
on  using  heart  stimulants,  of  which  the  most  efficacious  in  my  hands 


282  CLINICAL  MEDICINE 

has  been  a  pill  of  powdered  squills,  i  dram;  caffein  citrate,  |  dram; 
and  strychnin  sulphate,  i  gr.,  made  into  30  pills;  one  before  each 
meal. 

These  patients  also  do  well  under  5-gr.  doses  of  sodium  iodid  three 
times  a  day,  and  should  always  take  one  of  Blancard's  pills  of  iodid 
of  iron  after  breakfast  and  dinner.  It  is  well  for  such  patients  to 
carry  with  them  a  bottle  of  aromatic  spirits  of  ammonia  and  take 
a  teaspoonful  of  it  in  water,  to  which  should  be  added  from  another 
bottle  15  drops  of  tincture  of  nux  vomica  whenever  they  feel  any 
symptoms  of  cerebral  anemia,  such  as  dizziness  or  ringing  in  the  ears. 

Bradycardia  is  not  uncommon  during  convalescence  from  pneu- 
monia, when  the  above-mentioned  pill  may  be  administered  with 
advantage. 

CHRONIC  VALVULAR  DISEASE 

In  any  case  of  chronic  valvular  disease  the  practical  question  is. 
How  long  can  the  heart,  by  its  own  powers,  compensate  for  the  difficul- 
ties in  the  circulation?  The  mechanism  of  compensation  is  so  varied 
and  so  constantly  differs  in  each  case  that  it  neither  can  be  defined  nor 
classified.  Thus,  the  heart  is  no  mere  pump,  but  a  vital  organ,  whose 
actions  are  determined,  both  in  health  and  in  disease,  by  muscular 
and  by  nervous  forces,  the  degree  of  either  of  which  varies  in  each 
case.  To  estimate,  therefore,  how  long  these  compensations  will 
last  or  how  soon  they  will  fail  is  impracticable,  and  our  only  resource 
is  to  note  the  necessary  factors  in  the  case. 

The  first  factor  is  hypertrophy  of  the  musculature  of  one  or  more 
of  the  heart  cavities.  This  is  according  to  the  law  that  muscles  hyper- 
trophy in  proportion  to  the  work  which  they  have  to  perform,  but 
though  hypertrophied  muscles  seem  to  be  in  all  respects  like  normal 
muscles,  it  is  well  to  note  that  hypertrophied  muscles  more  easily 
degenerate  than  normal  muscles.  We  must  expect,  therefore,  that 
hypertrophy  of  the  heart  walls  cannot  last  indefinitely  as  such,  but 
that  sooner  or  later  they  will  degenerate,  usually  with  dilatation  of 
the  affected  cavities.  For  how  long  this  terminal  dilatation  or  degen- 
eration may  be  postponed  is  the  practical  aim  of  the  instructed 
physician. 

To  do  this,  we  should  bear  in  mind  what  strengthens  muscular 
tissues  in  health.  First,  muscular  power  depends  directly  upon 
oxygenation.  In  all  animals  muscular  power  is  proportioned  to  the 
activity  of  breathing.  Huxley  calculates  that  if  we  could  take  in  as 
much  oxygen  from  every  part  of  our  bodies  as  the  flea  does,  instead 


CHRONIC    VALVULAR    DISEASE  283 

of  by  the  restricted  apparatus  of  our  lungs,  a  man  could,  unaided, 
move  the  whole  massive  structure  of  Newgate  prison.  But  in  our  own 
species  we  constantly  meet  with  illustrations  of  this  law.  Sedentary 
habits  in  us  invariably  induce  weakness  in  all  muscular  tissues,  because 
we  scarcely  breathe  one-half  as  actively  when  seated  as  we  do  when 
walking.  On  that  account  women  suffer  from  organic  muscular  weak- 
ness far  more  than  laboring  men,  along  with  debility  of  all  muscular 
functions,  so  that  many  of  them  are  constipated  throughout  life,  and 
are  prone  to  relaxation  of  the  pelvic  organs,  with  a  consequent  disturb- 
ance of  their  circulation.  Thus  arise  many  derangements  of  uterine 
functions,  including  that  of  parturition  itself,  which  are  unknown  to 
women  who  work  like  men  out  in  the  fields.  I  have  repeatedly  known 
elderly  men  who  were  troubled  with  weakness  of  the  bladder  to  have 
these  disabilities  disappear  during  a  prolonged  vacation  out-of-doors. 
It  is  due  to  this  law  that  Oertel's  treatment  of  cardiac  debility  by 
carefully  regulated  hill-climbing  was  so  successful.  On  the  same  prin- 
ciples, the  administration  of  iron  is  of  great  value  in  conditions  of 
cardiac  debility.  The  one  use  of  iron  as  a  remedy  is  that  it  increases 
hemoglobin,  and  by  so  doing  increases  the  amount  of  oxygen  in  the 
blood.  It  is  by  the  iron  which  the  blood  contains  that  we  breathe, 
and  the  practical  question  is  how  to  have  the  iron  assimilated,  as  we 
mentioned  in  the  treatment  of  chlorosis.  Naturally,  the  iron  which  is 
contained  in  our  food  is  almost  infinitesimal  in  quantity,  and  we  know 
very  little  of  the  methods  by  which  iron  becomes  a  natural  ingredient 
of  the  red  corpuscles.  Whenever  we  give  iron  as  a  medicine  the  doses 
are  far  larger  than  it  is  possible  for  the  system  to  assimilate,  so  that  it 
is  excreted  unchanged  by  the  bowels  and  thus  blackens  the  feces.  If 
anyone  should  have  the  mainspring  of  his  watch  broken,  he  could  not 
remedy  it  by  putting  his  watch  in  a  bag  of  watch-springs,  but  this  is 
scarcely  better  than  the  way  in. which  we  give  doses  of  iron  to  be 
swallowed.  A  great  many  unknown  nutritive,  metabolic  processes 
intervene  between  iron  put  in  the  alimentary  canal  and  iron  in  the  red 
corpuscle.  Moreover,  iron  is  wholly  useless,  if  not  mischievous,  in 
the  treatment  of  any  form  of  febrile  anemia.  It  is  thus  of  no  use  in 
the  treatment  of  the  anemia  of  pulmonary  phthisis,  but  should  be 
administered  in  all  non-febrile  anemias,  care  being  taken  to  combine 
it  with  whatever  remedies  promote  the  appetite  and  digestion.  In  all 
conditions  of  cardiac  debility  without  fever  iron  should  be  our  chief 
reliance  among  drugs.  Thus,  in  the  cardiac  debility  of  elderly  persons, 
shown  by  a  tendency  to  swelling  above  the  ankles,  I  am  accustomed  to 
administer  iron  in  the  following  prescription: 


284  CLINICAL  MEDICINE 

Black  Tonic  (Mist,  ferri  et  ammon.  carb.) 

I^.     Ammon.  carb 3iss; 

Ferri  ammon.  cit 5  j; 

Tinct.  nucis  vomicae 3ij; 

1  Tinct.  quassicC  \  

Tinct.  gentian,  i  ^     ' 

Syrup,  aurantii g iij; 

Aquae  camphorae 5  v. 

Sig. — Tablespoonful  in  water  after  meals. 

For  every  case,  therefore,  of  threatened  heart  failure  the  aim  of  the 
physician  should  be  to  have  his  patient  breathe  the  open  air  by  night, 
if  possible,  as  well  as  by  day,  just  as  in  the  treatment  of  tuberculosis. 
These  principles  find  a  special  illustration  in  the  management  of 
patients  with  aortic  regurgitation. 

AORTIC  STENOSIS 

In  comparison  with  aortic  insufficiency,  aortic  stenosis  is  a  rare 
disease,  usually  associated  with  extensive  calcareous  changes  in  the 
arteries  of  elderly  patients.  The  ventricles  in  this  condition  may  be 
much  hyper trophied  without  any  corresponding  dilatation.  It  is 
curious  that  inspection  may  fail  to  reveal  any  area  of  cardiac  impulse, 
while  percussion  is  always  less  than  the  wide  area  of  dulness  in  aortic 
insufficiency,  but  palpation  often  gives  us  a  thrill  of  marked  intensity. 
On  auscultation,  a  rough  systoHc  murmur,  heard  loudest  at  the  aortic 
cartilage  and  transmitted  upward  into  the  carotids,  is  the  most  constant 
symptom.  A  similar  murmur  of  moderate  intensity  may  not  neces- 
sarily mean  obstruction  at  the  orifice,  but  may  arise  from  roughening 
of  the  valves  or  from  the  anemic  state  of  the  blood,  but  in  aortic  ste- 
nosis the  murmur  has  a  much  harsher  quality,  is  louder,  and  may  even 
be  musical.  The  pulse  in  aortic  stenosis  is  small,  but  regular.  When 
the  stenosis  is  extreme,  symptoms  of  deficient  blood-supply  to  the  brain, 
such  as  faintness  and  dizziness,  may  occur.  When  degeneration  and 
dilatation  set  in,  insufficiency  of  the  mitral  valve  develops,  with  its 
accompanying  dyspnea,  cough,  and  dropsy  of  the  legs.  In  diagnosis 
a  sphygmographic  tracing  is  very  characteristic  of  this  lesion,  showing  a 
curve  of  slow  rise,  a  broad  well-sustained  summit,  with  a  slow  decline 
in  every  respect,  quite  opposite  to  the  tracings  in  aortic  regurgitation, 
the  pulse  meantime  showing  none  of  the  characteristics  of  the  collaps- 
ing Corrigan  pulse. 

Treatment. — For  aortic  stenosis  the  best  treatment  is  by  aconite 
given  in  sufficient  doses  to  slow  the  pulse;  that  is,  in  doses  of  from  5  to 
10  drops  of  the  tincture,  of  the  Pharmacopeia  of  1890. 


AORTIC   REGURGITATION  285 

AORTIC  REGURGITATION 

The  commonest  cause  of  aortic  regurgitation  is  from  rheumatic 
endocarditis  altering  the  valves,  so  that  they  do  not  properly  close 
together  during  the  diastole  of  the  ventricle.  This  disorder,  when  rheu- 
matic in  its  origin,  may  occur  in  childhood,  when,  without  arthritis, 
chorea  may  have  affected  the  child  because  chorea  causes  endocarditis 
oftener  at  that  time  of  life  than  arthritis.  Probably  on  this  account 
we  read  of  aortic  incompetence  being  due  to  congenital  malformations 
of  the  valves,  but  such  congenital  affections  must  be  rare.  In  endo- 
carditis, as  we  have  explained,  not  only  do  the  valves  become  distorted, 
but  the  chordae  tendinae  may  become,  by  shortening,  the  most  efficient 
agents  in  the  production  of  this  lesion,  but,  however  produced,  aor- 
tic incompetence  may  be  readily  compensated  for  by  increased 
hypertrophy  of  both  left  ventricle  and  auricle,  so  that  many  cases  may 
live  for  years  but  Httle  affected  by  what  may  at  any  time  become  a 
very  serious  heart  affection.  One  thing  is  always  certain,  that  owing 
to  the  regurgitation  through  the  incompetent  valve  into  the  left 
ventricle  already  filled  during  diastole,  the  heart  has  to  perform  much 
heavier  work,  as  it  throws  out  a  larger  quantity  of  blood  than  normal 
with  each  systole. 

As  the  valves  become  more  and  more  incompetent,  the  most  recog- 
nizable changes  may  be  due  to  pulsation  of  the  peripheral  arteries. 
Thus,  on  baring  the  arm  and  flexing  the  elbow,  the  artery  may  be  seen 
to  jump,  as  it  were,  in  its  bed  from  the  middle  of  the  forearm  to  the 
middle  of  the  arm.  At  the  same  time  both  carotids  visibly  pulsate,  and 
if  the  arm  be  elevated  the  pulse-beat  of  the  heart  may  be  noticed  in 
the  changing  color  of  the  finger-nails  during  systole  and  diastole.  The 
pulse  at  the  radial  presents  the  so-called  "water  hammer"  or  Corri- 
gan's  pulse,  consisting  of  a  full  beat  followed  by  immediate  collapse, 
characteristics  never  found  in  a  normal  pulse.  "The  sphygmographic 
tracing  is  very  characteristic,  the  high  ascent,  the  sharp  top,  the  quick 
drop,  in  which  the  dicrotic  notch  and  wave  are  very  shghtly  marked." 

As  we  have  remarked,  the  double  work  performed  by  the  heart  in 
this  trouble  leads  to  hypertrophy  of  its  walls  more  marked  than  in  any 
other  cardiac  affection,  causing  what  is  termed  the  "bovine  heart," 
which  may  weigh  35  or  40  oz. 

So  long  as  the  patient  is  not  affected  by  arteriosclerosis,  good  com- 
pensation may  last  for  years,  but  so  soon  as  general  arterial  thickness 
sets  in,  the  terminal  stages  of  this  affection  begin.  Instead  of  the  ini- 
tial shortness  of  breath  and  tendency  to  palpitation,  dilatation  of  the 
heart  cavities  commence,  which  is  shown  by  great  increase  in  the  per- 


286  CLINICAL  MEDICINE 

cussion  area  of  dulness,  particularly  downward  and  to  the  left.  So 
long  as  dilatation  has  not  occurred,  the  heart  impulse  is  strong,  and  the 
extent  of  the  wave  of  the  beat  against  the  chest  wall  becomes  very 
apparent.  When  dilatation  with  weakening  occurs,  the  clinical  symp- 
toms change,  the  breathing  is  very  short,  and  signs  of  cerebral  anemia 
develop,  such  as  dizziness  and  ringing  of  the  ears,  with  a  marked  tend- 
ency to  syncope.  There  is  no  other  affection  of  the  heart  which  is  so 
frequently  the  cause  of  sudden  death,  but  mental  derangements  are 
also  very  pronounced,  the  patients  are  subject  to  terrifying  dreams, 
and  while  awake  may  have  very  uncomfortable  delusions.  These 
patients,  therefore,  should  be  carefully  watched,  for  they  often  attempt 
suicide.  Owing  to  the  disturbance  of  sleep,  they  frequently  cannot 
lie  down,  but  sleep  sitting  in  a  chair.  It  is  in  them  that  a  full  dose 
of  opium  at  night  produces  the  best  effects. 

Auscultation  usually  affords  the  most  unmistakable  signs.  At  the 
base  of  the  heart  a  pronounced  murmur  occurs  which  is  propagated 
down  midsternum  to  the  apex,  but  not  beyond  the  apex  to  the  left. 
Not  uncommonly  a  thrill  can  be  felt  accompanying  the  murmur,  and 
sometimes  present  even  in  the  carotids.  I  have  known  this  murmur 
to  be  musical.  The  only  murmur  with  which  it  may  be  confounded 
is  the  presystolic  murmur  of  mitral  stenosis,  but  usually  these  two 
murmurs  can  be  easily  differentiated.  In  some  cases  the  murmur  is 
not  most  distinct  at  the  base  of  the  heart,  but  rather  at  midsternum. 
Its  coincidence  with  the  diastole,  however,  is  always  recognizable. 

When  compensation  begins  to  fail,  remedies  should  be  carefully 
selected  which  steady  the  heart.  Digitalis  is  contra-indicated,  owing 
to  its  property  of  constricting  the  arteries.  Its  place  may  be  taken 
by  powdered  squills,  in  a  dose  of  i  gr.,  along  with  caffein  citrate,  from 
I  to  2  gr.,  and  spartein  sulphate,  J  gr.,  taken  in  pill,  three  or  four  times 
in  twenty-four  hours.  For  disturbed  sleep  the  following  prescription 
may  be  tried  (chloral  and  morphin) : 

I^.     Ac.  hydrocyanici  dil 5ij; 

Chloral 5ij; 

Magendie  solution gtt.  xxxvj; 

Syr.  aurant -. giss; 

Aq.  menthe ad.  5vj.— M. 

Sig. — Dessertspoonful  to  tablespoonful,  at  night. 

If  this  fails,  opium  is  our  best  remedy,  from  J  to  |  or  i  gr.,  taken 
at  night,  with  4  or  5  gr.  of  powdered  rhubarb  to  prevent  constipation. 


MITRAL    STENOSIS  287 

MITRAL  STENOSIS 

Separate  mention  may  be  made  here  of  the  production  of  mitral 
stenosis.  It  is  difficult  to  account  for  its  greater  prevalence  in  females 
than  in  males;  thus,  at  the  Royal  Infirmary  of  Edinburgh,  during 
sixteen  years  (1893  to  1908)  there  were  324  males  and  523  females 
admitted  for  pure  mitral  obstructions.  In  the  majority  of  cases  the 
two  mitral  cusps  become  united,  so  that  the  valve  presents  the  form  of 
a  hollow  cone  pointing  downward  toward  the  apex  of  the  heart,  with 
an  outlet  that  may  have  only  the  diameter  of  a  goose-quill.  This  is 
more  common  in  children  than  another  form,  which  is  called  the 
button-hole  or  irregular  slit  aperture,  most  frequent  in  adults.  The 
changes  in  the  walls  of  the  auricles  in  mitral  stenosis  are  usually  very 
pronounced.  As  remarked  before,  mitral  stenosis  may  also  be  ac- 
companied by  mitral  incompetence. 

Mitral  stenosis  is  always  a  serious  affection,  largely  because  it  is 
progressive.  The  patients  are  short  breathed,  on  account  of  the 
special  tendency  to  engorgement  of  the  lungs.  On  this  account 
also  they  are  subject  to  cough,  with  passive  congestion  of  the  bronchial 
tubes.  In  no  heart  affection  also  is  there  such  a  tendency  to  hemopty- 
sis, which,  if  due  to  mitral  stenosis,  is  best  treated  by  wet  cupping  over 
the  precordial  region.  It  should  also  be  borne  in  mind  that  the  en- 
gorgement of  the  auricle  may  be  so  great  as  to  cause  sudden  death. 
This  is  the  cardiac  lesion  in  which  palpation  alone  may  be  diagnostic, 
for  on  placing  the  tip  of  the  finger  at  midsternum  over  the  mitral 
orifice  a  strong  thrill  may  be  felt,  which  is  usually  limited  in  its  area. 
Percussion  shows  an  increased  area  of  dulness  across  the  base  of  the 
heart.  Auscultation  gives  very  characteristic  signs,  a  second  sound 
being  much  more  clearly  accentuated  at  the  pulmonary  than  at  the 
aortic  area.  The  pathognomonic  murmur  is  heard  over  the  site  of 
the  mitral  valve,  which  is  definitely  presystolic  in  time.  It  is  loud 
and  harsh,  increasing  in  its  intensity  until  it  abruptly  ceases  with  the 
first  sound.  This  murmur  does  not  transmit  in  the  characteristic 
directions  of  the  murmur  of  mitral  incompetence,  but  it  may  readily 
be  confounded  with  the  murmur  of  aortic  regurgitation,  which  occurs 
during  diastole  and  which  is  often  accompanied  by  a  thrill,  but  this 
thrill  is  not  so  pronounced  as  in  mitral  stenosis.  It  may  be  distin- 
guished by  the  presystolic  murmur  of  mitral  stenosis,  being  much  more 
harsh  than  the  aortic  murmur  and  by  its  abrupt  termination  with  the 
first  sound.     The  pulse  is  small  and  very  frequently  irregular. 

Owing  to  engorgement  of  the  lungs  in  mitral  stenosis,  it  is  a  serious 
matter  to  have  any  bronchitis  develop  in  these  patients.     This  com- 


288  CLINICAL  MEDICINE 

plication  is  very  apt  to  occur  in  them,  and  should  be  promptly  treated 
by  the  remedies  already  mentioned  for  that  complaint. 

Treatment. — The  dyspnea  of  mitral  stenosis  is  not  to  be  relieved 
by  digitalis,  a  drug  so  often  administered  in  heart  disease  in  a  routine 
and  mistaken  mannfer  as  if  it  were  a  heart  tonic  for  all  purposes. 
Digitalis,  on  the  other  hand,  while  contracting  dilated  heart  cavities 
better  than  any  other  known  remedy,  yet  simultaneously  contracts 
all  the  arteries,  and  thus  raises  blood-pressure,  a  very  undesirable 
matter  in  mitral  stenosis.  Instead  of  digitahs,  powdered  squills,  in 
grain  doses,  may  be  prescribed  as  a  heart  stimulant,  along  with  i  to 
2  gr.  of  caffein  citrate,  and  J  gr.  of  spartein  sulphate,  along  with  from 
-^  to  -^  gr.  of  strychnin.  Iron  also  ought  to  be  administered,  as 
before  stated,  on  general  principles. 

MITRAL  REGURGITATION 

For  its  final  effects  mitral  regurgitation  produces  the  most  exten- 
sive lesions  of  any  affection  of  the  heart,  in  that  it  causes  dilatation  and 
hypertrophy  of  all  four  chambers  of  the  heart  in  the  following  order: 
First,  regurgitation  occurs  from  the  left  ventricle  into  the  left  auricle 
with  each  systole,  thus  further  distending  the  auricle  already  filled  with 
blood  as  it  comes  in  by  the  pulmonary  veins;  second,  with  each 
systole  of  the  left  auricle  a  larger  amount  of  blood  than  normal  is 
emptied  into  the  left  ventricle,  leading  to  its  dilatation  and  hyper- 
trophy; third,  the  blood  in  the  pulmonary  veins  is  so  jammed  back 
into  both  arteries  and  veins  of  the  lungs  that  the  right  auricle  is 
obliged  to  do  more  work  to  discharge  its  blood  into  the  lungs,  and 
thus  the  right  ventricle  becomes  dilated  and  hypertrophied;  lastly, 
the  right  auricle  is  unable  to  discharge  its  blood  into  the  right  ventricle 
without  more  than  usual  work,  on  account  of  the  stasis  of  blood  in 
the  cavity  of  the  right  ventricle.  Also  the  auricle,  therefore,  becomes 
dilated  and  hj^ertrophied.  This,  in  turn,  causes  tricuspid  regurgita- 
tion, so  that  the  whole  systemic  venous  system  becomes  distended 
with  blood,  causing  engorgement  of  the  liver  and  of  the  alimentary 
canal  generally. 

To  return  to  the  chronic  venous  stasis  in  the  lungs:  this  leads  to 
congestion  of  the  bronchial  mucous  membrane,  if  not  to  actual  hemop- 
tysis. Chronic  bronchitis,  therefore,  with  cough  is  one  of  the  results 
of  mitral  incompetency.  Meantime,  this  condition  of  the  circulation 
in  the  lungs  leads  to  what  is  called  brown  induration  of  the  lung  tissue. 

In  no  form  of  heart  disease,  however,  are  the  compensatory  powers 
of  the  heart  so  well  illustrated  as  in  mitral  regurgitation.     Owing  to 


MITRAL   REGURGITATION  289 

hypertrophy  of  both  the  right  and  left  ventricles,  the  discharges  of 
blood  from  those  cavities  may  continue  normal  in  amount  for  many 
years,  so  that  the  patients  are  unaware  that  they  have  any  serious 
cardiac  derangements,  except  that  they  are  more  prone  than  usual 
to  short  breath;  often  they  are  wholly  unaware  of  having  any  heart 
trouble  until  it  is  accidentally  discovered  by  a  physician  on  ausculta- 
tion. After  a  time,  however,  from  any  of  the  many  causes  of  malnu- 
trition of  the  heart,  compensation  begins  to  fail,  one  of  the  first  signs 
being  paleness  with  a  slight  tinge  of  jaundice  and  blueness  of  the  lips; 
but  patients  may  present  these  symptoms  for  a  long  time  without  be- 
ing seriously  discommoded.  As  failure  in  compensation  increases, 
the  general  symptoms  become  more  and  more  serious.  The  over- 
filled veins  begin  to  leak  into  the  tissues,  causing  dropsy  of  the  feet, 
which  increases  upward  until  ascites  accumulates  in  the  abdomen 
and  in  the  serous  sacs  of  the  pleura,  along  with  general  anasarca. 
The  patients  finally  are  unable  to  lie  down,  and  are  apt  to  have  dis- 
tressing attacks  of  sudden  awakening  on  falling  asleep.  Digestion 
becomes  much  impaired  from  the  general  venous  stasis  in  the  whole 
alimentary  tract;  the  kidneys  also  become  congested,  the  urine  dimin- 
ishes in  amount,  is  high  colored,  and  loaded  with  urates,  the  breath- 
ing naturally  becomes  short  and  labored,  with  a  supervention  of  pulmo- 
nary edema,  and  death  usually  occurs  from  asthenia. 

Mitral  incompetency  occurs  from  two  widely  different  conditions, 
the  first  ordinarily  occurring  in  early  Hfe  from  endocarditis,  producing 
valvulitis,  with  results  which  we  have  already  described.  But  the  most 
serious  forms  of  mitral  regurgitation  may  occur  without  any  valvulitis 
at  all,  and  that  is  when  the  heart  is  hypertrophied  from  extracardiac 
causes.  Thus,  it  occurs  in  chronic  Bright's  disease  from  widespread 
arteriosclerosis.  The  heart,  from  its  increased  work  in  keeping  up 
the  circulation  through  the  obstructed  arteries,  first  hypertrophies 
and  then  dilates,  so  that  the  auriculoventricular  orifice  may  no  longer 
be  perfectly  closed  during  the  ventricular  systole.  Often,  however, 
other  causes  of  muscular  debility  produce  the  same  result,  one  of  these 
is  long-standing  abuse  of  alcoholic  stimulants.  It  should  be  remem- 
bered that  this  is  one  of  the  commonest  causes  of  premature  senility, 
both  in  the  muscular  and  in  the  nervous  system,  characterized  in  the 
heart  by  degeneration  of  the  myocardium  and  consequent  dilatation 
of  the  heart  cavities.  In  addition  to  this,  every  strain  in  lifting  or  in 
manual  labor  tends  to  the  same  result,  so  that  we  find  in  hospitals  many 
such  patients  from  the  lower  classes,  and  thus  account  for  the  greater 
frequency  of  this  form  of  heart  disease  among  men  than  among  women. 

19 


290  CLINICAL  MEDICINE 

It  should,  therefore,  be  borne  in  mind  that  mitral  regurgitation  may- 
have  nothing  to  do  with  valvular  disease. 

Treatment. — It  is  for  the  effects  of  mitral  regurgitation  that  digi- 
talis is  our  chief  anchor.  Digitalis  works  best  in  cardiac  dilatation  by 
itself  diminishing  the  dilatation  of  the  cavities,  which  it  does  by  cramp- 
like contraction  during  the  systole.  Hence,  digitahs  should  not  be 
given  when  there  is  no  dilatation.  As  it  restores  the  heart  more  nearly 
to  its  normal  conditions,  it  greatly  increases  the  heart's  power  to  re-es- 
tablish the  natural  flow.  One  of  its  first  effects  is  to  increase  the  flow  of 
urine,  and  so  assist  the  removal  of  dropsy  and  of  effusions  into  the 
serous  cavities.  The  lungs  also  become  rid  of  their  pulmonary  edema, 
and  the  embarrassed  portal  circulation  becomes  so  far  relieved  that 
the  gastro-intestinal  digestion  is  likewise  improved.  Along  with 
digitalis,  however,  other  remedial  measures  should  be  simultaneously 
adopted,  particularly  those  which  prevent  the  action  of  the  digitalis 
in  contracting  the  arteries.  Nitroglycerin  and  other  nitrites,  on 
account  of  their  evanescent  action,  are  not  as  permanently  efficient 
vasodilators  as  aconite,  as  we  have  already  mentioned  in  the  treat- 
ment of  arteriosclerosis.  These  all,  however,  may  be  of  great  service 
in  preventing  arterial  contraction,  and,  therefore,  should  be  adminis- 
tered with  each  dose  of  digitalis.  Aconite  should  be  given  in  15-drop 
doses  every  three  or  four  hours  along  with  the  digitalis.  Other  ad- 
vantageous adjuncts  during  the  administration  of  digitalis  are  purga- 
tives, such  as  a  full  dose  of  Epsom  salts,  taken  in  the  morning,  or  the 
compound  cathartic  pill,  taken  at  night  twice  a  week.  Calomel,  in 
fact,  is  one  of  our  best  diuretics.  The  compound  jalap  powder  is  also 
one  of  the  best  purgatives  to  be  used  alternately  with  the  other  reme- 
dies of  this  class,  because  no  single  purgative  should  be  too  exclusively 
employed. 

When  the  kidneys  are  embarrassed  it  may  be  administered  in  the 
form  of  a  compound  diuretic  pill  consisting  of  i  gr.  of  calomel,  i  gr. 
of  powdered  squills,  and  i  gr.  of  digitalis.  Should  the  dropsy,  how- 
ever, continue  to  increase,  puncture  of  the  legs  below  the  knees  may  be 
resorted  to,  especially  by  means  of  Southey's  capillary  tubes.  The 
skin  of  the  legs,  as  it  has  been  devitalized  by  the  subcutaneous, 
watery  effusion,  should  be  very  carefully  disinfected  before  making  the 
punctures,  for  sloughing  or  even  gangrene  may  occur.  It  is  remarkable 
that  when  successful  the  dropsy  may  thus  be  very  strikingly  relieved 
by  removing  so  many  of  the  mechanical  causes  of  circulatory  embar- 
rassment. 

In  all  cases  of  anasarca  due  to  mitral  regurgitation  the  administra- 


ANGINA   PECTORIS  29I 

tion  of  digitalis  should  be  begun  by  full  doses  of  a  tablespoonful  of 
the  ofi&cinal  infusion  given  four  times  in  the  twenty-four  hours,  after 
the  bowels  have  been  opened  by  a  dose  of  5  gr.  of  calomel  with  35  gr.  of 
jalap  powder.  A  tablespoonful  of  the  infusion  of  digitalis  should  be 
taken  four  times  in  the  twenty-four  hours  for  three  days  and  then 
intermitted,  after  which  the  compound  diuretic  pills  already  men- 
tioned should  be  administered  for  three  more  days;  after  this  30  drops 
of  a  mixture  of  equal  parts  of  tincture  of  digitaHs,  tincture  of 
strophanthus,  and  tincture  of  nux  vomica  may  be  continued  for  a 
number  of  days.  Meantime  doses  of  iron  should  be  kept  up  in  a 
mixture  containing  10  to  15  drops  of  the  tincture  of  chlorate  of 
iron  with  i  dram  of  the  sweet  spirits  of  niter,  and  i  dram  of  the  syrup 
of  ginger  in  peppermint- water. 

Functional  Disorders  of  the  Heart 
paroxysmal  tachycardia 

This  strange  affection  I  have  often  met  in  my  experience.  It 
has  no  connection  with  other  forms  of  tachycardia,  such  as  Graves' 
disease  or  tabes.  I  have  found  it  to  occur  exclusively  in  persons 
after  forty  years  of  age.  The  attacks  set  in  abruptly,  without 
any  connection  with  the  taking  of  food  or  exercise,  and  in  a  few  minutes 
the  pulse  rises  to  200  or  more.  It  is  remarkable  that  the  patients,  as 
a  rule,  have  no  dyspnea,  and  are  only  discommoded  by  their  extreme 
tachycardia;  the  attacks  may  subside  suddenly  after  twenty-four  hours; 
in  some  cases  not  for  three  or  four  days. 

Treatment. — I  have  found  no  treatment  efficacious  for  the  attacks, 
though  on  general  principles  I  would  advise  absolute  physical  quiet, 
for  cases  have  been  reported  of  patients  dying  from  this  complaint 
with  symptoms  of  heart  failure.  I  may  say  that  no  cardiac  sedatives, 
such  as  aconite  or  veratrum  v'.ride,  seem  to  have  any  effect  on  the 
attacks. 

ANGINA  PECTORIS 

The  symptoms  of  this  deadly  affection  in  typical  cases  are  those  of 
sudden  onset  of  agonizing  pain  in  the  chest,  with  the  sense  of  great  con- 
striction, as  if  the  chest  were  in  a  vise,  and  radiation  of  the  pain  up  the 
neck  and  down  the  left  arm,  often  to  the  fingers,  with  a  feeling  of  numb- 
ness and  tinghng.  Accompanying  this  pain  is  a  premonition  of  impend- 
ing and  immediate  dissolution.  Thus,  a  gentleman  of  my  acquaint- 
ance exclaimed  in  his  only  attack,  "I  did  not  know  that  death  would 
be  so  painful,"  and  immediately  expired.       Other  cases  of  angina 


292  CLINICAL  MEDICINE 

pectoris,  however,  are  not  so  severe,  as  they  may  frequently  recur  for 
months,  or  even  years,  during  which  the  characters  of  the  attacks  are 
the  same  as  in  the  fatal  cases,  only  more  temporary  and  less  severe. 
In  these  cases  the  exciting  causes  are  varied,  mental  emotion 
being  one  of  the  commonest.  This  was  recognized  by  John  Hunter, 
who  complained  that  anyone  who  vexed  him  might  be  the  cause  of  his 
death,  which  was  true,  for  he  died  in  a  fit  of  anger.  Other  causes  are 
from  sudden  muscular  effort,  for  these  attacks  but  rarely  occur  when 
the  patient  is  quiet.  Another  cause  of  these  attacks,  which  it  is 
doubtful  to  class  as  either  a  cause  or  an  effect,  is  from  the  supervention 
of  gastric  flatulence,  for  many  cases  are  quickly  reheved  by  an  eructation 
of  gas.  A  still  further  exciting  cause  is  from  exposure  to  sudden  cold, 
as  might  be  expected  from  the  effects  of  cold  in  contracting  so  many 
widely  spread  arteries  of  the  surface.  It  is  curious  that  this  affection 
occurs  so  rarely  among  women.  In  my  private  practice  I  have  known 
of  only  two  women  who  succumbed  to  it,  one  having  her  first  attack  in 
the  morning,  and  a  return  three  hours  afterward,  when  she  quickly  died. 
Another  had  repeated  attacks  for  many  months  before  she  finally  suc- 
cumbed in  the  last  one.  The  theories  of  the  production  of  angina  pec- 
toris are  numerous,  but  to  my  mind  the  most  probable  one  is  that  of 
Heberden,  to  whom  the  profession  owes  the  first  treatise  on  this  dis- 
ease. He  ascribed  the  attacks  to  cramp  of  the  heart,  either  from  over- 
work or  other  cause  of  spasm  of  the  coronary  arteries;  thus  cramp 
may  be  induced  in  the  muscles  of  the  calf  of  the  leg  by  too  prolonged 
dancing,  but  on  account  of  the  situation  of  those  muscles  this  is  a 
trivial  affair;  while  a  cramp  of  the  heart,  if  at  all  prolonged,  must 
necessarily  be  fatal.  A  further  confirmation  of  this  theory  is  the  fact 
that  any  muscle  may  be  thrown  into  tonic  cramp  by  ligation  of  its 
artery  or  similar  means  of  shutting  off  its  arterial  supply.  Cramp 
of  the  heart,  therefore,  may  be  readily  imagined  as  occurring  in  angina 
pectoris  from  spasm  of  one  or  more  of  its  coronary  arteries.  It  is 
curious  that  experimental  ligation  of  a  main  coronary  branch  may  at 
first  seem  to  have  but  slight  effect,  but,  in  a  shorter  or  longer  period 
of  time,  the  animal  suddenly  dies.  About  the  physical  causes  of  this 
affection  there  is  but  little  disagreement,  as  sclerotic  changes  in  the 
coronary  arteries,  if  not  fibrosis  in  the  myocardium,  are  so  often  found. 
One  of  my  patients  who  died  suddenly  during  his  first  attacks,  at  au- 
topsy showed  no  microscopic  changes  in  the  coronaries  or  in  the  heart 
walls,  but  it  is  doubtful  if  careful  microscopic  search  might  not  have 
revealed  degeneration  both  in  the  coats  of  the  coronaries  and  in  the 
myocardium. 


ANGINA   PECTORIS  293 

Symptoms. — It  is  curious  that  the  pulse  is  often  so  little  affected 
during  an  attack,  being  usually  neither  irregular  in  rhythm  nor  changed 
in  size.  As  a  rule,  however,  the  pulse  is  small  and  of  high  tension, 
the  face  is  ashy  pale,  and  the  skin  is  bedewed  with  cold  perspiration. 
Besides  the  radiations  of  pain  which  we  have  already  mentioned,  they 
may  radiate  to  distant  parts.  Thus,  Osier  mentions  a  case  in  which 
they  radiated  to  the  jaw,  and  another  to  the  left  testicle.  This  af- 
fection, as  we  might  expect  from  its  connection  with  arteriosclerosis,  is 
markedly  hereditary;  thus,  in  the  well-known  case  of  Dr.  Thomas 
Arnold,  it  occurred  in  three  successive  generations  of  his  family. 
The  rule  is  that  it  occurs  in  persons  who  are  considerably  past  middle 
life.  When  it  develops  in  persons  under  twenty-five  years  of  age  the 
presumption  is  strong  that  it  is  due  to  syphihtic  disease  of  the  aorta 
and  coronaries.  I  was  once  called  to  see  a  patient  who  was  thirty- 
five  years  of  age,  who  admitted  that  he  had  had  syphiKs.  I  went 
out  to  get  some  remedies,  and  on  my  return  I  found  him  dead,  and 
I  was  told  that  because  the  pains  had  passed  off  he  arose  and  tried  to 
move  a  piano,  and  while  doing  so  dropped  dead.  As  might  be  ex- 
pected, angina  pectoris  very  frequently  develops  in  the  course  of  aorti- 
tis, and  may  be  one  of  the  first  symptoms  of  the  beginning  of  an 
aortic  aneurysm.  Severe  anginose  pains  also  are  frequent  accompani- 
ments of  aortic  regurgitation. 

Treatment. — For  the  attacks  themselves  we  must  rely  upon  im- 
mediate vasodilators,  and  for  this  purpose  the  patient  should  always 
have  with  him  capsules  of  so-called  perles  of  nitrite  of  amyl,  which 
should  be  broken  and  inhaled.  It  is  wonderful  how  quickly  a  relief 
of  the  paroxysm  may  be  thus  attained,  and  this  is  an  indication  of  the 
cramp  being  caused  by  arterial  spasm.  Nitroglycerin  also  is  of  great 
service,  and  may  be  administered  in  a  prescription  of  |  gr.  dissolved 
in  6  oz.  of  water.  A  teaspoonful  of  this  contains  -^  gr.  of  nitroglycerin. 
In  chronic  cases  a  patient  should  carry  a  small  bottle  of  this  solution, 
so  as  to  swallow  a  teaspoonful  of  it  with  the  first  onset  of  pain  in  w^alk- 
ing  or  in  muscular  exertion.  I  have  had  patients  who  became  accus- 
tomed to  this  dose,  and  who  had  to  take  two  to  four  times  the  quantity 
afterward  to  produce  the  same  effect.  The  sign  of  having  taken 
enough  is  from  throbbing  of  the  temples  with  headache.  No  danger, 
however,  need  be  apprehended  from  this  drug.  A  patient  should 
also  swallow  a  dram  of  Hoffmann's  anodyne  or  compound  spirits  of  sul- 
phuric ether,  taken  in  a  little  water,  for  this  is  promptly  followed  by 
eructation  of  gas  from  the  stomach.  A  similar  relief  may  be  obtained 
by  taking  a  teaspoonful  of  the  spirits  of  chloroform.     The  real  treat- 


294  CLINICAL  MEDICINE 

ment,  however,  should  be  prophylactic.  Every  patient  subjected  to 
true  anginose  symptoms  should  systematically  take  the  remedy  for 
conditions  of  arteriosclerosis  which  we  have  already  spoken  of,  namely, 
5  gr.  of  sodium  iodid,  three  or  four  times  a  day,  along  with  4  to  6  drops 
of  equal  parts  of  Balfour's  Uquor  strychni  hydrochlorici  and  Hquor 
arsenici  hydrochlorici.  The  main  reliance  must  be  upon  aconite, 
which  should  be  given  in  doses  of  10  drops  of  the  tincture  of  the  Phar- 
macopeia of  1890  four  times  a  day,  and  continued  for  months  together. 
I  have  had  elderly  patients  who  have  thus  continued  the  aconite  for 
three  and  four  years,  and  who  were  obliged,  on  omitting  it,  to  return 
to  its  use  because  of  a  return  of  anginose  symptoms. 

FALSE  OR  NEUROTIC  ANGINA  PECTORIS 

In  contrast  with  true  angina,  attacks  of  this  affection  are  very 
frequent  in  women.  During  the  attacks  the  patients  become  rest- 
less and  often  very  cold,  especially  in  the  feet,  with  severe  pains  about 
the  heart,  often  causing  faintness  or  cyanotic  change  in  the  face. 
It  is  also  common  for  them  to  have  a  great  deal  of  flatulence  in  the 
bowels,  the  pulse  may  be  very  small  and  irregular,  and  the  general 
symptoms  are  not  unlike  an  aggravated  attack  of  hysteria. 

Treatment  of  the  attacks  themselves  should  be  by  Hoffmann's 
anodyne,  or  teaspoonful  doses  of  the  spirits  of  chloroform.  The  pro- 
phylaxis of  these  affections  is  based  mainly  upon  measures  for  the  relief 
of  chronic  hysteria,  of  which  a  course  of  aloetic  purgatives,  or  else 
lo-gr.  doses  of  benzoate  of  sodium,  with  4  or  5  gr.  of  powdered  rhu- 
barb, several  times  a  day,  should  be  adopted. 


CHAPTER   III 

DISEASES  OF  THE  LYMPHATICS 

HODGKIN'S  DISEASE 

In  1832  an  eminent  anatomist  at  Guy's  Hospital  described  Hodg- 
kin's  disease  as  a  specific  derangement  of  the  blood,  characterized 
by  enlargement  of  the  lymphatic  glands  in  different  parts  of  the 
body  which  are  distinct  from  other  g'andular  derangements  often  con- 
founded with  it.  Thus,  it  is  separate  from  tuberculous  adenitis  by  the 
entire  absence,  in  typical  cases,  of  tubercle  bacilli,  whether  on  micro- 
scopic examination  or  by  experimental  inoculation.  It  also  entirely  dif- 
fers from  tuberculous  adenitis.  It  is  distinguished  at  once  from  leukemia 
by  the  examination  of  the  blood,  which  shows  no  increase  in  the  forma- 
tion of  leukocytes.  It  is  also  different  from  lymphosarcomatous  tumors, 
for  in  it  the  enlarged  glands  do  not  implicate  surrounding  textures  in 
their  growth,  nor  show  any  true  metastases,  as  do  sarcomata.  Another 
feature  in  Hodgkin's  disease  is  that  the  enlargements,  however  great 
or  widespread,  remain  individually  discrete,  not  producing  infiltra- 
tions anywhere.  Another  clinical  feature  is  that  the  enlarged  glands 
often,  without  any  apparent  reason,  diminish  in  size  to  such  an  extent 
that  they  may  temporarily,  at  least,  seem  to  disappear.  The  only 
characteristic  change  has  been  found  in  the  bone-marrow,  which  in 
some  instances  is  altered  into  a  rich  lymphoid  tissue.  As  in  other 
affections  of  the  blood-forming  functions  of  the  bone-marrow,  its  true 
nature  and  etiology  are  as  yet  unknown. 

This  affection  occurs  oftener  in  males  than  in  females,  and  at  vari- 
ous ages,  but  most  commonly  in  adolescents.  Its  clinical  features  are 
that  it  begins  with  enlargement  of  the  glands  in  one  side  of  the  neck, 
oftener  the  left.  It  may  continue  for  an  indefinite  period  before  it 
involves  the  glands  on  the  other  side  of  the  neck.  From  the  neck 
it  then  proceeds  to  involve  the  thoracic  glands,  especially  those  in  the 
mediastinum,  more  commonly  than  in  the  axilla.  It  may  then  appear 
in  the  groins,  and  meanwhile  invade  the  lungs  with  lymphoid  growths, 
also  the  liver,  the  spleen,  and  kidneys. 

As  it  progresses,  anemia  becomes  pronounced,  though  not  so 
marked  as  in  leukemia,  the  red  corpuscles  rarely  falling  below  2,000,000 

295 


296  CLINICAL  MEDICINE 

per  c.mm.  One  of  the  characteristic  features  of  the  disease  is  that  its 
glandular  enlargement  often  encroaches  upon  organs  so  as  to  inter- 
fere with  their  functions.  I  was  once  called  in  consultation  by  Dr.  A. 
Monae  Lesser  for  a  supposed  stricture  of  malignant  disease  of  the 
esophagus,  through  which  the  doctor  could  not  pass  an  esophageal  tube. 
This  diagnosis  was  rendered  probable  by  the  age  of  the  patient,  being 
sixty-seven,  but,  upon  percussing  his  spine,  I  found  an  extensive  area 
of  dulness  opposite  the  fourth  and  fifth  dorsal  vertebrae.  I  then  asked 
the  patient  whether  he  could  swallow  liquids  when  he  was  lying  down 
on  his  left  side,  whereupon  he  answered  that  he  could.  This  proved 
that  the  pressure  on  the  esophagus  was  outside  that  tube,  and  on  fur- 
ther examination  I  soon  found  enlarged  glands  in  his  abdomen,  and 
pronounced  them  a  case  of  Hodgkin's  disease,  which  diagnosis  was  sub- 
sequently verified  at  autopsy.  These  glandular  enlargements  go  on 
increasing  and  causing  the  local  disturbances  with  the  functions  of 
the  intestine  and  other  abdominal  organs,  until  the  patient  sickens  and 
dies  from  both  anemia  and  emaciation.  Fever  is  a  common  but  ir- 
regular symptom  of  the  disease,  but  only  doubtfully  connected  with 
the  disease  process  itself. 

Histologically,  the  enlargements  in  Hodgkin's  disease  differ  alto- 
gether from  those  in  any  other  known  complaint,  and  never  show  any 
tendency  to  implicate  the  surrounding  textures  in  which  they  occur. 

Treatment. — As  to  treatment,  a  good  deal  has  been  said  in  favor 
of  the  employment  of  the  x-rays,  which  may  diminish  the  size  of 
the  enlarged  glands,  but  it  is  doubtful  if  any  real  cures  have  followed 
this  measure.  On  the  other  hand,  the  administration  of  large  doses  of 
arsenic,  beginning  with  5  drops  of  Fowler's  solution  and  increasing 
to  20,  has  been  reported  as  actually  curing  the  disease,  though  this  is 
also  doubtful.  Phosphorus,  in  mineral  form,  may  also  be  tried  if  the 
arsenic  fails. 

Recently  Drs.  C.  H.  Bunting  and  C.  L.  Yates,  of  the  University 
of  Wisconsin,  claim  to  have  discovered  what  they  term  a  diphtheroid 
organism,  and  which  they  call  corynebacterium  Hodgkini,  in  the  blood 
and  tissues  of  patients  with  Hodgkin's  disease.  They  were  able  to 
cultivate  this  organism  and  then  inject  the  cultures  into  monkeys, 
with  the  result  of  producing  typical  glandular  swellings  in  all  respects 
corresponding  to  the  enlargements  in  the  axillae  and  groins  of  Hodg- 
kin's disease. 


CHAPTER    IV 
DISEASES  OF  THE  BONES  AND   JOINTS 

CHRONIC  FIBROSITIS,  OR  CHRONIC  MUSCULAR  RHEUMATISM 

This  affection  occurs  in  persons  past  middle  life,  and  prevails  most 
among  those  who,  Hke  fishermen  and  sailors,  are  frequently  exposed 
to  cold  and  wet  weather.  It  is  not  due  to  an  inflammation,  rheumatic 
or  otherwise,  of  the  muscles  themselves,  but  rather  to  an  inflamma- 
tion of  the  fibrous  sheaths  of  the  muscles.  These  sheaths  hold  the 
different  muscular  bundles  together,  and  in  many  respects  bear  the 
same  relations  to  the  muscles  that  the  bark  does  to  the  tree,  because 
both  the  blood-vessels  and  the  nerves  supplying  the  muscles  must 
first  traverse  these  sheaths.  Fibrositis,  therefore,  is  sure  to  occasion 
atrophy  of  the  implicated  muscles,  as  well  as  constant  pain  on  move- 
ment. This  is  often  strikingly  exempUfied  in  the  wasting  of  the  top 
of  the  shoulder  when  the  deltoid  muscle  is  involved  in  this  affection; 
similarly,  when  the  hip  is  separately  attacked.  As  these  fibrous  sheaths 
end  in  tendons  which  are  attached  to  bones,  especially  of  joints,  they 
become  very  tender,  both  to  pressure  and  to  movement,  and  thus 
cause  serious  crippling  of  the  joints.  It  is  customary  to  call  this 
affection  muscular  rheumatism,  but  it  does  not  respond  at  all  to  the 
ordinary  remedies  for  rheumatism,  such  as  the  salicylates,  etc.  Like 
all  infl  mmations  which  involve  fibrous  tissues,  such  as  syphilitic 
periostitis,  the  patients  are  very  susceptible  to  any  lowering  of  the 
weight  of  the  atmosphere,  usually  called  "fall  of  the  barometer,"  so 
that  these  patients  have  very  sensitive  barometers  of  their  own  which 
correctly  inform  them  of  the  approach  of  a  storm.  The  reason  for 
this  is  that  the  nerves  are  closely  bound  to  their  fibrous  surroundings, 
and  are  put  upon  a  painful  stretch  such  as  cannot  occur  in  soft  tissues 
like  those  of  the  liver. 

Treatment.— The  main  indication  for  treatment  of  fibrositis  is  to 
deal  with  its  local  manifestations  by  the  best  relaxant  that  we  pos- 
sess for  muscles  stiffened  by  any  cause,  namely,  warm  water.  Douches 
of  water  at  a  temperature  of  from  95°  to  98°  F.  on  a  badly  stiffened 
shoulder,  for  example,  used  for  twenty  minutes  three  or  four  times  a 
day  will  be  sure  not  only  to  relax  all  the  contracted  muscles,  but  also 

297 


298  CLINICAL  MEDICINE 

to  restore  the  circulation,  and  thus  the  nutrition,  of  the  part.  Where 
muscles  all  over  the  body  are  affected  these  warm  baths  should  be 
used,  accompanied  in  every  case,  whether  local  or  general,  by  active 
friction.  As  might  be  expected,  no  part  of  the  body  should  be  so  care- 
fully protected  in  this  affection  as  the  skin.  The  patient  should  never 
omit  wearing  flannel,  and  should  sleep  between  blankets  or  flannel 
sheets,  as  the  pains  are  very  apt  to  be  aggravated  during  the  night. 
The  skin  should  be  rubbed  on  retiring  with  a  lime-water  Hniment 
applied  warm,  and  when  the  joints  are  especially  involved  the  bella- 
donna Hniment  is  of  great  service. 

Or  the  following  liniment  may  be  efficacious: 

Liniment,  aconiti  \ 

Liniment,  belladonnse    r aa  5j; 

Liniment,  chloroformi   -' 

Menthol 5j- 

Ft.  liniment. 

Or, 

Camphor 5 iij; 

Tincture  of  opium 5  j> 

Heat  by  putting  bottle  in  warm  water. 

Either  of  these  can  be  applied  warm. 

By  systematic  attention  to  the  above-mentioned  measures  the  dis- 
ease may  be  arrested.  Otherwise  the  affection  may  progress  from 
the  impKcated  tendons  at  their  attachments  to  the  articular  structures 
themselves,  causing  erosion  of  the  cartilages,  and  changes  in  the  syno- 
vial membranes,  leading  ultimately  to  permanent  crippHng  of  the 
joints. 

ARTHROPATHIES 

The  textures  which  make  up  a  joint  are  the  least  vascular  of  all 
tissues.  Thus,  the  eye  is  an  organ  which  contains  within  itself  a 
representative  of  every  tissue  of  the  body  except  the  reproductive 
tissues;  and  among  them  a  most  perfect  example  of  what  a  cartilage 
is  in  the  cornea,  which  does  not  even  have  a  single  capillary  blood-vessel 
penetrated.  The  functions  of  joints  also  are  chiefly  mechanical,  con- 
sisting of  bones  tipped  with  cartilage  and  enclosed  in  a  bag  called 
the  synovial  membrane,  which  secretes  the  synovial  fluid  for  the  pur- 
pose of  lubricating  the  moving  bony  structures,  and  which  also  covers, 
for  a  certain  distance,  the  tendons  and  ligaments  of  the  joints.  This 
bag  is  open  at  each  end  and  is  there  attached  to  the  bone.     Being  so 


ARTHRITIS    DEFORMANS,    OR    RHEUMATOID   ARTHRITIS  299 

simple  in  its  functions,  arthritis  or  inflammation  of  joints  is  the  least 
differentiated  of  all  inflammations,  their  chief  symptom  being  pain 
on  movement  of  the  part,  so  that  we  are  little  guided  by  the  symp- 
tom pains  in  the  etiology  of  the  different  forms.  In  one  form,  namely, 
gouty  arthritis,  we  seem  to  have  an  example  of  what  an  insoluble  in- 
gredient in  the  blood  (urate  of  soda)  does  when  it  circulates  about  such 
a  non- vascular  structure;  for  it  is  very  apt  to  be  arrested  there  and  to 
produce  inflammation  by  its  presence,  like  any  other  foreign  body. 
It,  therefore,  commonly  begins  with  the  most  remote  joint  in  the  body, 
namely,  the  great  toe.  The  other  inflammations  of  joints  are  usually 
associated  with  microbic  infections,  such  as  the  Diplococcus  rheumati- 
cus  of  Poynton  and  Payne,  and  the  gonococcus,  in  so-called  gonorrheal 
rheumatism,  or  it  may  be  the  pneumococcus  or  the  agent  of  scarlatina; 
also  in  fibrositis,  which  is  often  named  muscular  rheumatism.  In 
fact,  the  term,  "rheumatism"  is  frequently  applied  to  any  affections  of 
joints  which  have  in  common  the  symptom  pains  accompanying  joint 
movement.  A  good  example  of  this  is  in  that  chronic  and  severe  dis- 
ease commonly  called  rheumatoid  arthritis,  but  better  named  arthritis 
deformans,  which  certainly  has  no  rheumatic  element  about  it,  and  in 
which  all  remedies  for  true  rheumatic  infections  are  of  no  avail. 

ARTHRITIS   DEFORMANS,   OR  RHEUMATOID  ARTHRITIS 

Arthritis  deformans  may  be  divided  into  two  principal  forms:  one 
in  which  the  soft  tissue,  such  as  the  synovial  membrane,  becomes 
largely  involved,  with  proliferation  of  its  fringes  and  folds.  The  joint 
then  may  first  be  uniformly  swollen  and  distended  with  the  synovial 
fluid.  Mechanical  results,  as  it  would  seem,  then  follow  from  prolif- 
eration of  the  fringes  of  the  synovial  membrane  which  may  greatly 
interfere  with  the  articular  movements,  and  soon  lead  to  the  destruc- 
tion of  the  articular  cartilages,  so  that  the  bony  surfaces  rub  upon  one 
another  and  become  what  is  called  eburnated,  Kke  surfaces  of  ivory. 
Ere  long  great  deformity  of  the  joint  occurs,  or  even  subluxation,  from 
the  unequal  pull  of  the  attached  muscles.  This  is  particularly  illus- 
trated in  the  distortion  of  the  fingers,  with  which  this  disease  often 
begins. 

Etiology. — For  a  long  time  this  joint  disease  was  classed  among 
the  arthritic  lesions,  which  undoubtedly  occur  in  purely  nervous  dis- 
eases, such  as  tabes,  but  of  late  attention  has  been  chiefly  directed  to 
supposed  infections,  in  accordance  with  the  frequent  connections  of 
different  forms  of  arthritis  with  definite  infections,  analogous,  as  we 
have  remarked,  to  rheumatic  arthritis  and  arthritis  by  the  gonococcus. 


300  CLINICAL   MEDICINE 

A  diligent  search,  therefore,  has  been  made  for  such  infecting  agents 
in  this  disease.  Thus,  Ballantyne,  Poynton  and  Payne,  Chauffard,  and 
others  have  found  organisms  in  the  joints,  and  suggestive  results  have 
followed  the  injection  of  cultures  in  animals.  The  most  probable  de- 
duction of  this  sort,  however,  is  by  Still,  who  observed  in  children 
not  only  the  characteristic  joint  changes,  but  also  enlargement  of  the 
lymphatic  glands  and  of  the  spleen.  A  true  demonstration,  however, 
of  the  infecting  agent  or  agents  of  this  disease  has  not  yet  been  ac- 
complished, and  we,  therefore,  must  continue  to  treat  of  its  morbid 
anatomy  and  its  accompanying  clinical  symptoms.  I  much  doubt 
whether  those  Uttle  hard  knobs,  so  often  found  at  the  sides  of  distal 
phalanges  in  middle-aged  women,  called  Heberden's  nodes,  have  any 
connection  with  this  disease. 

A  second  form  of  this  affection  should  be  named  osteitis  deformans, 
for  it  is  chiefly  characterized  by  deformities  and  outgrowths  connected 
with  the  bony  structures  of  the  joints.  Owing  to  the  multiform  symp- 
tomatology according  to  the  regions  affected,  many  authorities  divide 
this  complaint  into  various  forms,  in  my  opinion  unjustifiably,  be- 
cause it  is  really  one  disease  in  them  all,  whether  it  occurs  in  children 
or  in  old  persons.  When  it  involves  the  spine  the  intervertebral  car- 
tilages gradually  disappear  and  bony  outgrowths,  in  time,  produce 
a  virtual  ankylosis,  so  that  the  whole  spine  becomes  rigid  as  well  as 
deformed,  often  with  k5^hosis.  Not  uncommonly  the  spinal  nerves 
are  pressed  upon  as  they  issue  through  the  vertebral  foramina,  thus 
causing  severe  pain  in  their  course,  and  hence,  when  the  lower  part  of 
the  spinal  column  is  involved,  they  may  give  rise  to  sciatica.  Mean- 
time, certain  other  S3miptoms  may  develop  very  early,  such  as  muscu- 
lar wasting,  which  often  seems  independent  of  the  joint  or  body  derange- 
ments, and  not  secondary  to  want  of  use  of  the  muscles.  Subcutane- 
ous fibroid  nodules  are  occasionally  met  with,  which  should  not  be 
confounded  with  similar  formations  in  acute  rheumatism.  All  along 
the  pulse  is  quickened,  running  from  90  to  no,  a  feature  which  is  really 
diagnostic  of  the  complaint. 

Where  many  joints  are  affected  the  distribution  is  markedly  sym- 
metric.  There  is  no  affection  which,  in  typical  cases,  is  so  distress- 
ingly crippHng  in  its  development.  The  patient  may  lie  with  the 
knees  flexed  on  the  thigh  and  the  thigh  on  the  abdomen,  with  similar 
distortions  in  the  upper  extremities.  And  yet,  in  some  cases,  the 
hands  may  be  so  free  that  the  patient  can  sew  or  even  write.  The 
onset  of  this  disease  may  be  both  acute  and  polyarthritic  from  the 
beginning,  when  it  may  be  difficult  to  distinguish  it  from  rheumatism. 


PULMONARY   OSTEO -ARTHROPATHY  301 

the  affected  joints  being  both  swollen  and  tender,  but  its  subsequent 
intractable  progress  in  time  settles  the  diagnosis. 

This  disease  occurs  in  both  sexes,  usually  when  above  the  twentieth 
year,  though  children  may  also  be  affected.  A  number  of  exciting 
causes,  such  as  too  frequent  pregnancies  or  prolonged  lactation,  have 
been  assigned,  and  in  individual  cases  this  may  be  true,  but  in  the 
majority  of  instances  no  special  cause  can  be  given.  Also  in  a  great 
many  of  these  patients  decided  remissions  may  occur  from  time  to  time. 

Treatment. — This  malady  is  almost  invariably  progressive  and 
incurable.  One  case,  a  lady,  wife  of  a  physician,  who  had  been  pro- 
nounced as  unmistakably  affected  by  this  complaint  by  a  number 
of  eminent  medical  men,  was  apparently  cured  by  my  systemat- 
ically douching  the  throat  night  and  morning.  She  seemed  to  be  so 
well  that  she  omitted  these  douches  for  a  few  months,  and  then  re- 
lapsed, to  be  again  relieved  on  resuming  this  treatment.  But  it  must 
be  confessed  that  our  only  hope  Kes  in  the  direction  of  the  identifica- 
tion of  a  specific  microbe  as  its  cause,  thus  enabhng  us  to  treat  it  with 
its  own  vaccine. 

OSTEOMALACIA,  OR  FRAGILITAS  OSSIUM 

I  have  seen  but  one  case  of  this  rare  disease,  in  a  middle-aged  lady 
who  had  apparently  one  hundred  spontaneous  fractures,  some  of 
which  occurred  from  simply  turning  in  bed.  These  fractures  seemed  to 
heal  rapidly,  without  inflammation  or  pain.  This  patient,  however, 
survived  the  onset  of  the  complaint  only  two  years. 

Its  etiology  is  altogether  obscure.  Theoretically,  it  might  be  bene- 
fited by  an  administration  of  20  gr.  of  lactate  of  calcium  four  times 
a  day,  and  by  ^-gr.  pills  of  mineral  phosphorus  three  times  a  day. 

PULMONARY  OSTEO-ARTHROPATHY 

This  very  obscure  disease  begins  with  a  clubbing  of  the  fingers 
and  toes,  by  which  is  meant  changes  in  shape  of  those  parts,  consist- 
ing of  enlargement  of  the  nails,  both  longitudinally  and  transversely. 
This  must  be  distinguished  from  the  clubbing  of  the  fingers  occurring, 
often  Hmited  to  one  hand,  in  the  course  of  a  chronic  pulmonary  dis- 
ease, as  in  phthisis,  and  in  some  cases  of  heart  disease  due  to  venous 
engorgement.  In  conditions  that  interfere  with  the  circulation,  club- 
bing may  follow  and  be  unilateral  or  bilateral,  in  order  to  belong 
to  the  general  systemic  affection  called  pulmonary  osteo-arthropathy. 
Besides  the  initiative  clubbing  of  the  fingers  and  toes,  there  are  changes 
in  the  bones  and  joints  not  unlike  those  occurring  in  acromegaly, 


302  CLINICAL  MEDICINE 

but  different  from  that  disease  in  that  the  bones  of  the  face  are  not 
involved,  the  changes  being  hmited  to  the  enlargement  of  the  hands 
and  feet,  and  of  the  ends  of  the  long  bones,  chiefly  of  the  lower  three- 
quarters  of  the  forearm,  and  legs. 

But  the  special  feature  of  this  obscure  disease  is  its  usual  association 
with  disorders  of  the  lungs  or  of  their  appendages,  such  as  chronic 
bronchitis,  bronchiectasis,  pulmonary  phthisis  or  chronic  pleuritis,  and 
notably  empyema.  Take  it  all  in  all,  the  pathology  of  this  complaint 
is  very  obscure,  because  its  manifestations  are  so  numerous  and  differ- 
ent that  it  must  be  due  to  a  widespread  nutritional  disorder  of  un- 
known origin. 

PHOSPHORUS  NECROSIS 

A  specific  disease  of  the  jaw-bone  was  formerly  often  mentioned 
as  occurring  among  workmen  in  match  factories,  where  they  were 
exposed  to  the  fumes  of  phosphorus.  In  nearly  all  cases  reported  the 
disease  began  in  roots  of  decayed  teeth  and  then  spread  to  the  jaw- 
bone, itself  producing  a  necrosis  of  the  bone  and,  consequently,  ulcera- 
tion of  both  the  tissue  and  the  adjacent  parts.  This  led  to  enactments 
of  law  to  protect  the  workmen  from  this  danger  which  have  greatly 
lessened  its  occurrence.  This  good  result  may  also  be  due  to  modern 
changes  in  the  manufacture  of  matches,  particularly  in  the  case  of  the 
safety  matches,  which  can  only  be  lit  by  being  struck  against  a  spe- 
cially prepared  surface. 


CHAPTER    V 

DISEASES  OF   THE   RESPIRATORY  TRACT 

The  respiratory  tract  begins  in  the  nose  and  continues  into  the 
larynx,  and  from  there,  through  the  trachea  to  the  bronchi.  On  its 
way  it  crosses  the  ahmentary  tract,  which  begins  in  the  mouth.  No 
contrast  could  be  greater  than  between  these  two  tracts,  in  one  respect. 
The  respiratory  tract  is  the  only  portion  of  the  body  which,  in  health, 
is  quite  sterile,  that  is,  practically  free  from  micro-organisms,  as  micro- 
organisms are  filtered  out  from  the  inspired  air  by  the  hairs  which 
line  the  entrance  of  the  nostrils.  On  this  account,  when  any  accident 
causes  a  perforation  through  the  bronchial  tract  into  the  lung  tissue, 
no  abscess  is  then  formed  in  the  lung.  This  is  one  reason  that  Cal- 
mette's  theory  is  so  probable,  that  we  contract  tuberculosis,  not 
through  the  air  which  we  breathe,  but  by  what  we  swallow.  One 
exception  to  the  foregoing  is  in  the  case  of  the  virus  of  pohomyehtis, 
which  modern  researches  conclusively  prove  to  enter  through  the 
upper  nasal  passages,  but  the  virus  of  poliomyelitis  is  so  minute  in 
size  as  to  be  ultramicroscopic,  and  hence  may  escape  the  hairy  filter 
in  the  nostrils.  Fine  mineral  particles,  as  in  the  case  of  stone-cutters 
and  coal-miners,  become  lodged  in  the  air-vesicles,  but  it  is  certain  that 
they  do  so  by  means  of  inhalation  through  the  mouth. 

In  the  case  of  coal-miners  and  other  workers  in  a  dusty  atmosphere 
the  walls  of  the  air-vesicles  may  be  actually  blackened  by  the  deposit 
in  them  of  the  particles  inhaled,  to  which  condition  the  term  "pneumo- 
koniosis"  has  been  applied,  but  it  is  extraordinary  how  little  trouble 
these  deposits  occasion  until  we  meet  with  fine  particles  of  hard  silex  in- 
haled by  stone-cutters  while  at  their  trade,  or  powders  of  steel  breathed 
in  by  knife-grinders.  In  both  these  cases  chronic  inflammatory 
changes  in  the  walls  of  the  air- vesicles  are  set  up  which  afford  a  favor- 
able soil  in  which  tubercle  bacilli  grow,  thus  causing  stone-cutters'  and 
knife-grinders'  phthisis. 

Another  clinical  fact  is  also  significant,  and  that  is,  although  the 
bronchial  tract  may  be  bathed  with  the  most  abundant  or  even 
putrid  secretions,  the  general  system  does  not  suffer  from  the  absorp- 
tion of  such  injurious  materials  into  the  blood,  as  it  certainly  would 
if  they  were  in  contact  with  any  other  mucous  membrane.     Thus  a 

303 


304  CLINICAL  MEDICINE 

bronchiectatic  cavity,  however  large,  may  be  emptied  once  or  twice  a 
day  by  coughing  out  the  very  offensive  contents,  without  accompany- 
ing systemic  symptoms. 

THE  NOSE 

It  is  a  general  physiologic  law  that  the  innervation  of  each  inlet 
in  the  body  to  a  tract  is  associated  with  the  normal  functions  of  such  a 
tract.  This  is  strikingly  illustrated  in  the  case  of  the  nostrils  and  their 
contiguous  nasal  passages.  The  respiratory  tract  begins  with  the 
nostril  and  the  nose,  and  any  form  of  nasal  obstruction  may  seriously 
affect  the  functions  of  the  bronchi  further  on.  On  that  account  such 
physical  obstructions  as  nasal  polypi  may  have  direct  relations  to  the 
irregular  actions  of  the  bronchi,  setting  up  the  disorder  called  asthma, 
in  the  same  way  as  obstructions  at  the  outlet  of  the  urethra  may 
produce  widespread  disturbances  of  the  innervation  of  the  genito- 
urinary tract. 

CORYZA 

It  is  in  affections  of  the  respiratory  tract  that  the  principles  laid 
down  in  our  first  chapter,  on  "Catching  Cold,"  have  their  most  striking 
illustrations.  Thus,  acute  coryza,  while  it  may  begin  from  wetting 
of  the  feet,  is  ordinarily  caused  by  a  draft  of  cold  air  on  that  great 
center  of  vasomotor  association,  the  nape  of  the  neck.  When  at  all 
severe  the  whole  nasal  mucous  membrane,  as  well  as  those  of  the  supra- 
orbital canals,  become  first  congested,  and  then  affected  with  typical 
catarrhal  inflammations.  Its  initial  starting  from  a  cutaneous  area  is 
then  shown  by  the  widespread  sensitiveness  of  the  skin,  which  some- 
times follows  so  markedly  that  the  patients  are  aware  of  a  cold  draft 
from  an  open  door,  which  would  not  be  perceived  by  any  person  in  a 
normal  condition.  This  susceptibility  may,  by  repeated  attacks,  end 
in  chronic  catarrhal  inflammations  of  the  nose,  one  of  the  miseries  so 
often  brought  to  the  notice  of  rhinologists. 

Treatment.— Proper  treatment  of  these  patients,  therefore,  is  to 
apply  cold  sponges  or  douches  to  the  nape  of  the  neck  twice  or  three 
times  a  day,  while  locally  insufflations  of  8  gr.  of  aristol  in  2  drams  of 
bismuth  may  be  tried.  Cocain  and  adrenalin  may  also  be  used  as  ad- 
juvants, but  their  action  is  too  temporary  to  relieve  any  settled  catar- 
rhal inflammation,  which  may  be  far  better  treated  by  the  tonic  applica- 
tions of  cold  to  the  nape  of  the  neck.  In  many  cases  of  long-standing 
nasal  catarrh  the  Eustachian  tubes  also  become  involved,  with  produc- 
tion of  tinnitus  and  deafness,  which  may  be  relieved  by  dealing  only 
with  the  original  nasal  congestion.     Medicinally,  especially  at  the  be- 


EPISTAXIS  305 

ginning  of  acute  coryza,  a  dose  at  night  of  two  of  my  grip  pills  is  often 
effective.     (See  Influenza.) 

In  other  cases,  similar  to  its  good  effects  in  acute  bronchitis,  10  gr. 
of  urotropin  combined  with  10  gr.  of  sodium  benzoate  are  often  helpful. 

It  is  a  good  example  how  the  different  parts  of  every  mucous  tract 
are  affected  by  conditions  found  in  the  beginning  of  those  tracts,  that 
chronic  laryngitis  is  often  promptly  relieved  by  the  removal  of  a  nasal 
polypus,  or  by  the  correction  of  a  similar  obstruction  to  the  passage  of 
air  in  respiration. 

EPISTAXIS 

Epistaxis,  or  nosebleed,  may  be  due  either  to  local  causes  in  the 
mucous  membrane  of  the  nose  or  to  conditions  of  the  blood  itself. 
One  of  the  severest  cases  in  my  experience  was  in  a  young  man  who 
has  been  long  subject  to  severe  ague,  with  enlarged  liver  and  spleen. 
It  is  also  frequent  in  anemias  due  to  constitutional  conditions,  such  as 
in  leukemia  or  in  purpura.  It  is  particularly  frequent  in  the  onset  of 
typhoid  fever,  and  is  then  diagnostic.  When  due  to  local  causes  it  is 
usually  trivial,  but  it  should  be  remembered  that  the  veins  of  the  nasal 
passages  lie  in  bony  canals,  and  hence,  if  they  begin  to  bleed  they  are 
not  easily  stopped  unless  the  mucous  membrane  itself  is  made  to  con- 
tract upon  them.  Epistaxis  occurs  spontaneously  in  young  persons 
about  the  age  of  puberty,  particularly  in  families  characterized  by 
collections  of  small  stellate  looking  veins  radiating  from  one  center  on 
the  skin.  These  hemorrhages  usually  are  trivial  and  cease  sponta- 
neously, but  the  tendency  to  them  is  best  checked  by  applying  cold 
to  the  nape  of  the  neck,  as  directed  in  the  Treatment  of  Coryza. 

When  due,  however,  to  conditions  of  the  blood  and  not  to  local 
causes,  they  should  then  be  treated  accordingly.  One  of  my  worst 
cases  occurred  in  a  child  after  nasal  diphtheria.  In  this  case  the  blood 
trickled  down  the  posterior  nares  into  the  stomach,  and  was  then 
vomited  in  large  quantities,  which  might  easily  have  been  confounded 
with  hematemesis;  in  other  cases  the  blood  may  be  coughed  up  and 
thus  simulate  hemoptysis. 

When  due  to  conditions  of  the  blood  itself,  these  have  to  be  treated 
according  to  their  causes.  Thus,  in  malaria,  the  administration  of 
quinin  along  with  2  teaspoonfuls  of  paregoric  may  be  the  most  effect- 
ive, while  arsenic  should  be  given  in  leukemia.  The  best  local  remedy 
is  by  spraying  the  nose  every  fifteen  minutes  with  a  solution  of  adrena- 
lin. In  some  severe  cases,  however,  if  doses  of  15  gr.  of  the  chlorid 
of  calcium  every  three  hours  are  not  sufficient,  the  nostril  should  be 
plugged  from  behind,  as  directed  in  books  of  surgery. 
20 


3o6  CLINICAL  MEDICINE 

ASTHMA 

This  is  an  affection  characterized  by  disturbance  in  the  natural 
rhythm  of  the  two  acts  in  breathing,  namely,  inspiration  and  expira- 
tion. In  health,  expiration  begins  immediately  with  the  end  of  inspi- 
ration, but  in  asthma,  while  the  inspiration  is  not  interfered  with, 
difficulty  occurs  in  the  act  of  expiration,  making  the  latter  prolonged 
and  labored. 

Asthma  may  be,  though  rarely,  primary.  Such  a  case  I  once  had 
in  a  paitient  who  was  over  seventy  years  of  age,  and  w^ho  said  that 
he  had  been  born  asthmatic.  But  in  the  majority  of  cases  asthma 
is  caused  by  interruption  in  the  act  of  expiration  from  coughing. 
The  act  of  coughing  can  occur  only  in  expiration,  and  hence  prolonged 
coughing  from  any  cause  may  first  originate  asthmatic  breathing. 
Thus,  in  children,  asthma  frequently  supervenes,  and  may  last  for  life 
from  attacks  of  measles  or  whooping-cough.  From  this  it  is  evident 
that  chronic  bronchitis  is  very  apt  to  cause  asthmatic  attacks.  This 
being  so,  it  becomes  a  practical  question  to  decide  whether  the  asth- 
matic disorder  is  due  to  bronchitis  or  whether  it  occurs  without  bron- 
chitis, because  in  the  first  case  we  should  aim  to  cure  the  bronchitis, 
for  then  the  asthmatic  breathing  will  cease  of  itself.  On  the  other 
hand,  we  may  have  the  asthmatic  disorder  without  its  being  preceded 
by  any  bronchitis.  In  such  case  of  primary  asthma  the  affection  is  a 
pure  neurosis  involving  the  nerves  supplying  the  bronchial  muscles, 
and  must  be  treated  as  a  neurosis. 

The  mechanism  of  an  asthmatic  attack  should  be  clearly  under- 
stood. From  the  difficulty  of  expiration  the  residual  air  in  the  lungs 
constantly  increases,  with  the  result  that  the  air-vesicles  become  over- 
distended  and  the  whole  chest  seems  to  contain  too  much  air.  The 
diaphragm  is  pushed  down  and  the  ribs  move  but  little  in  outward 
expansion  during  inspiration.  The  breathing  then  becomes  mainly 
vertical  or  directly  up  and  down.  On  percussion  the  note  is  everywhere 
clear,  and  the  inflated  lung  overlaps  the  natural  area  of  percussion  dul- 
ness  over  the  heart.  It  is,  however,  on  auscultation .  that  the  most 
characteristic  signs  are  elicited.  In  cases  of  pure  asthma,  whisthng 
sounds,  called  sibilant  rales,  which  are  everywhere  present  and  wholly 
displace  normal  vesicular  breathing.  If  there  is  bronchitis  also  present, 
we  have  a  great  variety  of  sounds,  some  cooing,  others  crackHng,  or 
even  groaning,  according  to  the  size  of  the  bronchial  tube  in  which 
they  occur.  Meantime  the  aspect  and  the  movements  of  the  patient 
become  characteristic.  His  whole  frame  partakes  in  the  struggle  for 
air,  which  leads  him  voluntarily  to  try  to  expand  the  chest  yet  more 


ASTHMA 


307 


and  more.  He  strives  to  make  his  back,  shoulders,  and  head  immov- 
able, so  that  from  them  the  accessory  muscles  of  respiration  may  pull 
upon  the  already  tense  walls  of  the  thorax.  Hence,  he  fixes  his  arms 
or  plants  his  elbows  on  a  table  or  other  support,  while  his  head  is 
thrown  back,  his  mouth  panting,  his  eyes  widely  open  and  fixed,  and 
his  face  pale  and  bedewed  with  perspiration.  He  speaks  only  in 
monosyllables,  and  resents  everything  which  calls  him  off,  even  for  a 
moment,  from  his  efforts  to  breathe.  The  pulse  grows  small  and  feeble, 
and  the  patient  becomes  so  cyanotic  and  cold  that  his  wet,  clammy  skin 
and  ghastly  expression  are  apt  to  inspire  strangers  with  fear  of  his  near 
dissolution. 

The  duration  of  an  attack  'varies  .greatly,  not  only  in  different 
patients,  but  in  the  same  patient  at  different  times.  The  attack  may 
come  on  in  the  night  and  pass  off  soon  after  daylight,  or  it  may  be 
prolonged  into  a  series  of  exacerbations  and  incomplete  remissions  for 
several  successive  days  and  nights,  until  the  sufferer  becomes  almost 
fatally  exhausted.  In  like  manner,  the  subsidence  bears  little  relation 
to  the  severity  or  duration  of  the  attack.  Either  as  the  effect  of  reme- 
dies or  spontaneously,  the  breathing  may  become  suddenly  easier,  the 
rigidity  of  the  chest  walls  passes  off,  the  inspirations  grow  fuller  and 
the  expirations  shorter,  and  the  patient,  who  but  a  few  moments  be- 
fore seemed  about  to  perish  in  his  distress,  will  soon  return,  after  a 
moderate  expectoration  of  a  clear  frothy  mucus,  to  regular  and  natural 
breathing,  with  no  other  indications  of  his  recent  sufferings  than  an 
expression  of  fatigue.  At  other  times,  especially  if  bronchitis  super- 
venes, the  attack  passes  off  in  a  series  of  irregular  paroxysms  of  diffi- 
cult breathing,  alternating  with  coughing  and  free  expectoration.  In 
many  fully  developed  attacks,  however,  the  patient  has  to  watch 
carefully  for  its  decline  and  guard  against  all  causes  of  exacerba- 
tion or  relapse,  particularly  from  eating,  so  that  some  asthmatics  are 
obliged  to  go  to  bed  fasting  if  they  are  to  pass  that  night  free  from 
dyspnea. 

Etiology, — The  exciting  causes  which  will  develop  an  attack  in  asth- 
matics are  extremely  varied,  because  there  is  no  tract  the  nerves  of 
whose  mucous  membrane  are  so  sensitive  as  that  of  the  respiratory 
tract.  Thus,  the  nasal  mucous  membrane  is  often  the  seat  of  abnormal 
excitabihty,  as  we  might  expect  from  the  general  law  already  alluded  to, 
that  the  outlet  of  any  tubular  structure  is  always  closely  associated  in 
its  nerves  with  the  tract  itself  to  which  it  belongs. 

In  every  asthmatic,  therefore,  the  nose  should  be  carefully  exam- 
ined, because  many  old  cases  of  the  disease  have  been  cured  by  the 


308  CLINICAL  MEDICINE 

removal  of  nasal  polypi,  or  by  operations  which  rectify  abnormalities 
in  the  nasal  passages. 

Strong  odors  of  any  kind  are  mentioned  as  exciting  causes  in  such 
patients,  not  excluding  the  pleasant  fragrance  of  violets.  The  most 
pronounced  cases,  however,  are  reported  as  due  to  the  odors  of  animals, 
so  that  we  hear  of  cat  asthma,  or,  similarly,  from  the  odor  of  horses, 
and  particularly  the  various  sources  of  such  excitations  in  menageries. 
I  knew  of  one  case  in  which  a  man  insisted  that  a  cat  was  in  the  room, 
because  nothing  else  could  so  effect  him,  for  he  trembled  all  over,  and 
after  a  diligent  search  the  cat  was  found  hidden  behind  a  sofa. 

Next  to  the  respiratory  tract,  the  most  frequent  excitants  of  asth- 
matic attacks  proceed  from  the  alimentary  canal,  particularly  from  the 
stomach  and  duodenum,  and  receive  the  general  designation  of  "peptic 
asthma."  Partaking  of  too  hearty  a  meal,  especially  in  the  evening, 
is  apt  to  induce  an  attack  in  the  following  night.  Many  asthmatics 
are  unable  to  eat  freely  except  in  the  morning  or  at  noon.  In  other  cases 
susceptibiHty  is  limited  to  only  certain  articles  of  food,  which  for  them 
are  always  interdicted.  One  of  the  commonest  of  these  is  cheese. 
With  susceptible  people  mere  change  in  the  rate  of  breathing  will 
suffice  to  develop  an  attack.  Thus,  during  sleep  the  breathing  is  much 
slower,  and  this  change  is  enough  to  cause  nearly  all  asthmatics  to 
have  their  attacks  come  on  after  midnight. 

True  asthma  is  a  disease  sui  generis,  but  is  often  imitated  by  the 
effects  of  toxemia  such  as  in  gout  and  in  uremia.  But  in  both  these 
cases  there  is  a  significant  difference.  However  severe  an  attack 
of  true  asthma  may  be,  even  so  that  the  patient  seems  on  the  point 
of  dissolution,  he  is  not  alarmed;  but  in  uremia  he  often  is  so,  early 
in  its  onset.  In  the  gouty  cases  the  attacks  are  sudden,  nocturnal, 
and  quickly  accompanied  by  a  great  bronchial  flux  which  may  be  pink- 
ish from  capillary  hemorrhage.  A  patient  of  mine  once  expectorated 
two  large  basinfuls  of  such  mucus  between  midnight  and  morning,  but 
after  three  such  attacks  they  ceased  and  never  recurred. 

Asthma  may  begin  at  any  age,  as  in  the  case  already  referred  to  in 
which  the  patient  was  born  asthmatic.  As  to  sex,  there  is  an  apparent 
preponderance  of  males,  which  is  explained  by  their  liability  to  bron- 
chitis from  outdoor  exposure.  If  the  disease  supervenes  in  childhood,  as 
from  attacks  of  measles  or  whooping-cough,  the  prognosis  is  rather 
favorable  that  they  will  outgrow  it  after  puberty. 

There  are  no  primary  organic  lesions  characteristic  of  asthma,  but 
such  lesions  when  secondary  are  not  uncommon.  In  some  cases 
chronic  bronchitis  is  responsible  for  the  changes  found  both  in  the 


ASTHMA  309 

lung  texture  and  in  the  bronchial  tubes,  those  lesions  being  in  the  form 
of  emphysema  and  dilatation  of  the  right  chambers  of  the  heart,  with 
their  consequent  derangements  described  under  Chronic  Bronchitis. 
Lastly,  from  the  combined  derangement  of  the  pulmonary  circulation 
caused  by  the  intermittent  apnea  and  the  permanent  emphysema,  we 
have  a  tendency  to  bronchial  flux  to  relieve  the  congested  vessels,  which 
finally  adds  chronic  inflammation  to  chronic  hyperemia,  and  thus  es- 
tablishes the  vicious  circle  of  impeded  circulation  causing  bronchitis, 
and  bronchitis,  in  turn,  causing  progressive  circulatory  impediment. 

These  slowly  induced  effects  finally  produce  changes  of  per- 
sonal appearance  which  mark  old  asthmatics.  As  the  general  nutri- 
tion suffers  from  the  persistent  congestion  of  the  liver  caused  by  the 
impeded  outflow  of  the  right  heart,  these  patients  are  usuafly  thin, 
pale  or  cyanotic,  and  with  deficient  muscular  power.  The  eyes  are 
prominent  and  watery,  the  voice  is  weak,  the  gait  slow  and  measured, 
and  the  back  rounded,  often  to  great  deformity.  The  head,  however, 
is  always  thrown  back  between  the  elevated  shoulders,  and  the  trunk 
of  the  body  is  kept  so  rigid  that  the  arms  hang  passively,  swung  by  the 
movements  of  walking. 

Theories  about  the  actual  conditions  present  in  an  attack  of  asthma 
are  somewhat  discordant.  Many  ascribe  the  symptoms  to  be  alto- 
gether due  to  spasm  of  the  muscles  of  the  finer  bronchi,  but  this  does 
not  account  for  the  absence  of  dif&culty  during  inspiration.  Another 
view  is  that  asthma  is  due  to  implication  of  the  phrenic  nerve,  which 
causes  a  tonic  cramp  of  the  diaphragm.  This  theory  accounts  for 
nearly  all  the  symptoms  of  asthma,  but  leaves  some  unexplained,  par- 
ticularly those  of  bronchial  asthma. 

Treatment. — The  treatment  of  asthma  varies  according  to  the  aim 
in  view.  If  the  aim  be  to  relieve  the  distressing  dyspnea,  we  may 
have  a  great  variety  of  remedies  which  will  relieve  the  symptom  spasm, 
but  not  cure  the  disease  asthma.  Thus  the  different  members  of  the 
class  remedies  called  Solanaceag,  namely,  beUadonna,  hyoscyamus,  stra- 
monium, and  duboisia,  are  each  effective  and  seem  to  reheve  the 
paroxysms  immediately.  Many  asthmatics,  therefore,  can  cut  short 
for  years  the  asthmatic  spasm  by  the  inhalation  of  the  smoke  of  burn- 
ing stramonium  leaves,  but  they  simply  relieve  the  symptom  spasm 
and  do  not  cure  the  disease  asthma,  nor  lessen  the  frequency  of  the 
attacks.  The  only  true  remedies  for  asthma  are  arsenic  and  iodin,  but, 
as  we  have  remarked  in  our  article  on  Remedies,  the  agents  which 
prominently  relieve  the  disease  may  be  helped  in  their  action  by  the 
simultaneous  administration  of  the  remedies  which  relieve  the  symp- 


3IO  CLINICAL  MEDICINE 

toms.  My  common  prescription,  therefore,  for  the  treatment  of 
asthma  is : 

I^.     Potass,  iodid 3iss; 

Liq.  potas  arsen 3  j ; 

Spts.  eth.  sulph.  co §iiss; 

Tinct.  belladonnae 3  ij ; 

Syr.  aurant.  cort ad.  3vj. — M. 

Sig. — Two  teaspoonfuls  in  water  an  hour  after  meals. 

Belladonna  is  introduced  because  it  is  in  the  same  botanical  family 
as  stramonium.  The  active  principle  of  belladonna  or  atropin  is  often 
effective  when  given  h5^odermically  at  the  nape  of  the  neck  in  a  dose 

of  YTo  to  T5  gr- 

We  have  already  stated  that  when  asthma  supervenes  upon  chronic 
bronchitis,  treatment  of  the  bronchitis  should  take  the  lead.  It  was  for 
a  distressing  case  of  asthmatic  attacks  occurring  in  a  patient  who  had 
chronic  bronchitis  that  I  first  had  recourse  to  the  emulsion  of  Hnseed  oil 
for  the  treatment  of  this  disorder,  as  fully  detailed  in  the  article  on 
Bronchitis,  and  after  many  years  of  experience  with  this  remedy  I  have 
found  no  treatment  equal  to  its  systematic  administration  in  cases  of 
true  bronchitic  asthma. 

In  conclusion,  we  may  say  that  no  chronic  asthmatic  should  ever 
take  a  dose  of  diphtheria  antitoxin  as  usually  administered,  for  a 
number  of  cases  have  been  reported  of  such  patients  quickly  succumbing 
with  very  serious  symptoms,  both  cerebral  and  respiratory.  These  un- 
toward results  are  ascribed  to  anaphylaxis,  but  why  they  should  occur 
in  asthmatics  and  not  in  ordinary  patients  with  other  diseases  cannot  be 
explained,  because  the  subject  of  anaphylaxis  itself  is  one  of  the  most 
obscure  in  medicine. 

HAY-FEVER 

Hay-fever  or  hay-asthma  prevails  most  among  those  who  live 
in  cities,  and  who  have  nothing  to  do  with  hay.  In  New  York  it  is 
remarkably  characterized  by  its  supervention  on  the  20th  day  of 
August,  so  that  patients  who  would  leave  the  city  before  that  day 
by  going  to  sea  or  to  certain  locaHties  were  always  free  from  the 
disease.  Gentlemen  have  come  to  me  because  this  annual  visitation 
occurred  when  the  dry  goods  trade  was  at  its  height  and  thus  entailed 
upon  them  serious  inconvenience.  I  have  told  them  that  in  three 
years  they  might  be  rendered  immune  from  the  attack  by  commencing 
in  June  with  a  prescription  of  tincture  of  belladonna,  3  drams,  and  Fow- 
ler's solution  of  arsenic,  9  drams,  12  drops  of  this  mixture  three  times 


HAY-FEVER 


3" 


a  day,  taken  until  the  usual  advent  of  the  disease  in  August;  the  result 
being  that  in  the  first  year  of  this  medication  the  attack  would  be 
much  milder;  in  the  second  year,  milder  still;  while  in  the  third  year 
it  would  be  scarcely  perceptible. 

There  can  be  no  doubt  that  the  habits  of  Hfe  have  much  to  do  with 
the  susceptibihty  of  persons  to  this  common  complaint.  I  have  no 
doubt  that  this  affection  is  much  more  common  now  than  it  was  in 
the  days  of  our  forefathers,  and  this  has  suggested  to  me  the  surmise 
that  it  may  be  due  to  the  irritating  effects  on  the  nasal  passages  of  the 
use  of  illuminating  gas  in  our  houses.  It  is  not  by  any  means  true 
that  farmers  who  have  to  reap  hay  and  rye  are  so  prone  as  city-bred 
people  to  this  complaint.  Farmers  also  all  over  the  northern  states 
cultivate  buckwheat,  whose  odors  are  notoriously  prone  to  irritate  the 
respiratory  passages. 

I  know  of  a  patient  who  always  could  tell  instantly  when  buckwheat 
flour  was  brought  into  the  house,  though  he  might  be  up  on  the  top 
floor,  by  the  supervention  in  him  of  asthmatic  breathing. 

There  can  be  no  doubt  that,  as  Dunbar  has  shown,  this  affection  is 
produced  by  the  prevalence  in  the  atmosphere  of  pollen  from  a  vari- 
ety of  grasses,  particularly  rye,  and,  as  we  have  remarked,  buckwheat. 
But  that  does  not  account  for  the  absence  of  hay-asthma  in  many 
places,  such  as  in  Bethlehem,  N.  H.,  where  many  persons  resort  each 
year  to  escape  this  trouble.  In  the  Adirondacks,  also,  it  may  be  due 
to  the  absence  of  cultivated  crops  of  the  various  grains. 

Symptoms. — The  symptoms  of  this  complaint  usually  begin  much 
as  a  cold  in  the  head,  with  sneezing,  watering  of  the  eyes,  and  some  sen- 
sations in  the  supra-orbital  sinuses ;  in  many  cases  this  is  accompanied 
by  shght  fever;  if  not,  with  the  general  symptoms  of  having  caught  a 
bad  cold;  ere  long,  also,  the  lower  respiratory  passages  become  affected 
with  symptoms  of  bronchitis,  ending  in  many  cases  with  actual  signs 
of  asthmatic  breathing.  The  patients  become  very  susceptible  to 
all  drafts  of  cold  air,  evidenced  every  now  and  then  by  an  apparent 
relapse  of  the,  complaint.  Usually  the  attack  decHnes  in  about  ten 
days,  but  in  some  cases  it  hangs  on,  as  a  wheezing  bronchitis,  for  three 
weeks,  if  not  more.  The  appetite  is  lost  and  occasionally  digestive 
disorders  supervene.  I  have  found  that  the  continuous  use  of  the 
belladonna  and  arsenic  prescription,  above  given,  seems  to  shorten 
the  disease  more  than  the  usual  remedies  for  ordinary  bronchitis. 

A  milder  affection  is  also  commonly  called  the  "rose  cold,"  which 
comes  on  in  June,  and,  on  account  of  its  occurring  when  rose  blossoms 
are  most  numerous,  it  is  ascribed  to  the  inhalation  of  their  fragrance. 


312  CLINICAL  MEDICINE 

I  had  a  patient  once  who  was  very  subject  to  disturbances  of  an 
asthmatic  effect  if  he  smelt  very  fragrant  roses,  but  it  is  more  probable 
that  it  is  due  to  the  pollen  of  grasses,  as  in  the  case  of  the  disorder 
in  the  later  months  of  the  summer.  It  is  not  uncommon,  however,  for 
those  who  are  subject  to  rose  cold  to  be  affected  by  the  later  Au^ast 
complaint. 

ACUTE  LARYNGITIS 

Laryngitis,  as  a  primary  affection,  is  unknown,  being  rather  due 
to  the  extension  downward  of  a  "cold"  in  the  head;  its  first  symp- 
tom is  hoarseness,  from  swelling  of  the  mucous  membrane  of  the  vocal 
chords.  If  at  all  severe,  it  is  soon  accompanied  by  sore  throat,  and  at 
first  by  a  dry,  croupy  cough.  If  it  further  progresses,  there  is  aphonia, 
or  loss  of  voice.  These  symptoms  are  familiar  to  everyone  from  what 
is  popularly  termed  "catching  cold  in  the  throat."  The  practical  aim 
now  is  to  prevent  the  laryngitis  from  becoming  chronic  and  from 
progressing  further  downward  to  the  bronchi. 

It  is  quite  otherwise  when  any  part  of  the  larynx  is  invaded  by 
extension  of  any  morbid  process  occurring  in  parts  contiguous  to  the 
breathing  apparatus,  for  then  the  laryngeal  affection  may  soon  become 
dangerous  to  Ufe.  This  happens  in  all  membranous  exudations  which 
invade  the  larynx,  illustrated  particularly  in  laryngeal  diphtheria. 
No  such  processes  are  apt  to  remain  confined  to  the  lar3nix,  but  spread 
by  contiguity  to  the  trachea  and  bronchi,  as  we  have  already  mentioned 
in  speaking  of  laryngeal  diphtheria. 

We  have  referred  in  our  article  on  Erysipelas  to  the  dangerous 
supervention  of  edema  of  the  glottis  when  erysipelas  attacks  the 
throat.  This  complication  should  also  be  watched  for  in  cases  of 
small-pox  developing  in  the  mouth. 

Treatment. — ^We  have  also  alluded  to  the  distressing  larjmgitis 
which  occurs  in  pulmonary  tuberculosis.  When  the  larynx  is  affected 
in  the  course  of  any  disease,  particularly  in  diphtheria,  the  patient 
should  be  placed  under  a  tent,  which  is  conveniently  made  by  sus- 
pending an  open  umbrella  over  the  bed,  to  which  sheets  should  be 
attached.  Then  a  stream  of  vapor  from  a  kettle  of  boiling  water,  to 
which  one-third  of  syrup  molasses  is  added, — the  vapor  of  the  syrup 
itself  being  quite  soothing  to  the  mucous  membrane  of  the  larynx  and 
trachea, — is  led  into  this  tent.  The  stream  is  to  be  conducted 
from  the  mouth  of  the  kettle  in  a  large  tube,  of  the  size  of  the  arm, 
made  of  paper  lined  with  oiled  silk,  because  inhalation  of  steam  directly 
from  the  kettle  is  scalding;  our  object  being  rather  to  fill  the  whole 


TUBERCULAR    LARYNGITIS  313 

tent  with  the  vapor  of  the  boiling  water.     Nothing,  in  fact,  is  so  sooth- 
ing to  the  inflamed  laryngeal  membrane  as  this  steam  vapor. 

In  all  cases  of  chronic  laryngitis  the  throat  ought  to  be  douched 
twice  a  day  with  hot  water,  in  the  fashion  recommended  in  our  article 
on  Scarlatina  and  Diphtheria. 

EDEMA  OF  THE  GLOTTIS 

This  is  the  most  rapidly  fatal  of  all  affections  of  the  respiratory 
tract.  At  one  time  I  was  detained  only  a  few  minutes  from  visiting 
one  of  my  small-pox  wards,  only  to  find  on  my  return  that  a  patient 
with  confluent  small-pox  which  had  invaded  the  mouth  was  dead  from 
a  sudden  development  of  edema  of  the  glottis.  This  accident  is  also 
to  be  especially  dreaded  when  erysipelas  of  the  face  extends  to  the 
mouth,  but  it  may  unexpectedly  occur  also  in  any  one  of  the  exanthe- 
mata. The  diagnosis  of  its  approaching  onset  is  comparatively  easy, 
for  not  only  may  a  greatly  swollen  epiglottis  be  readily  seen  by  the 
laryngoscope,  but  may  be  felt  by  the  finger,  or  actually  be  seen  rising 
at  the  base  of  the  tongue.  No  time  should  be  lost  then  to  scarify  the 
swollen  contiguous  structures  by  a  long  scalpel,  and,  if  this  measure 
does  not  furnish  relief,  to  perform  tracheotomy  without  delay,  for  only 
thus  may  it  be  possible  to  save  life. 

CHRONIC   LARYNGITIS 

Chronic  laryngitis  is  usually  caused  by  repeated  attacks  of  acute 
laryngitis,  although  it  may  occur  as  an  independent  affection  in  per- 
sons who  customarily  strain  the  voice  in  public  singing  or  speaking. 
I  once  relieved  a  professional  singer,  who  greatly  dreaded  attacks  oi 
failure  of  her  voice,  by  having  her  suck  through  a  tube  equal  parts  of 
hot  milk  and  lime-water  in  small  quantities  for  over  an  hour  at  night. 
She  told  me  afterward  that  this  procedure  saved  her  from  retiring 
from  her  business. 

A  form  of  chronic  laryngitis  occurs  so  often  in  public  speakers  as  to 
go  by  the  name  of  "clergyman's  sore  throat."  An  examination  of 
the  throats  of  these  patients  shows  that  it  is  ahnost  invariably  ac- 
companied by  chronic  laryngitis  as  well,  and  is  best  treated  first  by  rest 
and  by  douching  the  throat  with  hot  water  and  chlorate  of  potash,  in 
the  maimer  spoken  of  in  the  treatment  of  scarlatinal  sore  throat. 

TUBERCULAR  LARYNGITIS 
This  affection  may  be  termed  the  most  distressing  of  the  many 
miseries  caused  by  tuberculosis.     In  the  majority  of  cases  it  is  second- 


314  CLINICAL  MEDICINE 

ary  to  tuberculosis  of  the  lung,  and  by  the  laryngoscope  the  vocal  chord 
corresponding  to  a  cavity  or  extensive  tuberculous  disorganization  in 
the  lung  is  shown  to  have  been  affected  by  being  constantly  bathed  with 
the  infected  sputum  from  that  lung.  In  other  and  the  worst  cases, 
however,  it  occurs  early,  while  only  a  moderate  focus  of  tuberculosis  is 
present  in  the  lung.  Why  the  ulcerative  process  of  the  chords  in  these 
cases  is  so  serious  is  not  easily  explained.  Not  only  are  the  vocal 
chords  involved,  but  the  glottis  itself,  with  the  epiglottis,  may  be  fairly 
burrowed  by  ulcerative  tracts.  Deglutition,  therefore,  becomes  very 
painful,  and,  in  bad  cases,  accompanied  by  regurgitation  into  the  nose. 
The  nutrition  of  the  patients  suffers  extremely,  as  they  dread  all  acts 
of  swallowing. 

Treatment. — Much  the  best  treatment  of  this  affection  is  to  apply 
powdered  opium,  i  part,  and  powdered  bismuth,  4  parts,  on  a  swab, 
directly  to  the  glottis.  A  4  per  cent,  solution  of  cocain  may  also  be 
used  as  a  local  spray. 

LARYNGISMUS  STRIDULUS,  OR  SPASMODIC  CROUP 

This  affection  occurs  often  in  infancy,  but  is  always  alarming  in  the 
symptoms.  A  child  goes  to  bed  apparently  quite  well,  but  is  awakened 
in  the  night  by  a  spasmodic  affection  of  the  vocal  chords,  accompanied 
by  a  brassy  cough  and  high-pitched  stridor  in  breathing.  This  may  or 
may  not  be  preceded  by  symptoms  of  slight  cough;  it  may  set  in, 
however,  from  irritation  produced  by  undigested  food.  It  subsides 
quickly  upon  the  action  of  an  emetic,  such  as  i  to  2  teaspoonfuls  of 
the  syrup  of  ipecac.  As  a  prophylactic  to  these  attacks  we  should 
use  cold  water  sponging  at  the  nape  of  the  neck  and  the  front  of  the 
chest,  followed  by  active  friction. 

When  these  attacks  occur  frequently  it  is  a  sign  of  general  consti- 
tutional debility,  for  which  nothing  is  better  than  cod-liver  oil. 

BRONCHITIS 

It  is  noteworthy  how  very  rarely  bronchitis  is  caused  by  the  nature 
of  the  air  which  we  breathe.  If  that  air  contains  any  irritating  sub- 
stances, it  is  stopped  by  spasm  and  coughing  in  the  larynx.  Instead, 
as  we  have  remarked  in  our  first  chapter,  bronchitis  comes  from  the 
skin,  which  has  to  be  attended  to  first  in  all  victims  of  chronic  bron- 
chitis. CHnically,  bronchitis  may  be  divided  into  two  forms,  acute  and 
chronic.  It  also  differs  altogether  from  pleurisy  and  pneumonia  by 
being  bilateral.  Hence,  whenever  severe,  the  patient  cannot  lie  down, 
but  must  sit  up.     Both  nostrils  are  widely  dilated,  and  the  mouth 


BRONCHITIS  315 

is  never  tightly  closed,  but  the  lips  are  partially  open.  The  lips  are 
not  drawn  tightly  across  the  upper  teeth  except  in  case  of  pain.  At 
first  acute  bronchitis  may  be  quite  dry  of  secretion  in  the  bronchial 
tubes,  but  the  mucous  membranes  are  then  much  tumefied,  and  their 
lumen  so  narrowed  that  the  dyspnea  and  cyanosis  may  be  pronounced. 
Auscultation  will  reveal  universal  fine  sibilant  rales  both  anteriorly 
and  posteriorly.  The  indication  now  is  to  promote  secretion,  for  that 
will  reduce  the  tumefaction  of  the  bronchial  mucous  membrane  and 
bring  on  cough  with  expectoration.  The  best  remedy  for  this  state  is 
tartar  emetic,  i  gr.  of  which  should  be  dissolved  in  a  teacupful  of  water, 
I  teaspoonful  of  which  may  be  taken  every  ten  minutes  until  nausea 
sets  in,  when  the  symptoms  at  once  become  modified,  with  cough  and 
expectoration. 

Symptoms. — Ordinarily,  acute  bronchitis  begins  with  signs  of  in- 
flammation of  the  bronchial  tubes,  with  both  pain  and  cough.  The 
pain  has  no  resemblance  to  that  of  acute  pleurisy  or  of  pneumonia,  but 
is  rather  a  sense  of  diffused  soreness  through  the  chest,  graphically 
denoted  by  the  gesture  of  the  patient,  who  passes  his  whole  hand 
over  the  front  of  his  chest.  Dyspnea  also  persists  for  some  time  from 
the  initial  swellings,  which  we  have  already  described.  This  dyspnea 
is  modified  by  more  abundant  secretion  along  with  coughing.  The 
physical  signs  then  are  of  distention  of  the  whole  thorax.  The  percus- 
sion-note is  everywhere  resonant,  but  it  is  then  that  the  signs  of  auscul- 
tation are  the  most  characteristic.  All  over  the  chest  both  sibilant 
and  crackling  sounds  are  heard,  sibilant  with  wheezing  where  bronchial 
spasm  predominates,  and  crackling  in  proportion  to  the  secretion. 
These  crackling  sounds  are  audible  both  on  inspiration  and  expira- 
tion. The  cough  also  has  a  very  characteristic  sound,  which  the  clin- 
ician should  note.  In  proportion  as  the  cough  is  squeaky  in  char- 
acter and  accompanied  with  wheezing,  it  denotes  more  or  less  asthmatic 
spasm  of  the  bronchial  tubes,  and  viscidity  of  the  secretion.  As  it 
becomes  more  liquid,  the  spasmodic  element  diminishes,  and  the  rales 
become  more  pronounced,  indicating  that  the  expectoration  is  now 
more  free.  Meantime  what  is  expectorated  is  less  mucoid  and  begins 
to  show  the  admixture  of  pus.  The  temperature  of  acute  bronchitis 
is  relatively  low,  not  often  reaching  103°  F. 

Treatment. — The  indications  for  treatment  are  to  cause  the  secre- 
tion to  be  as  liquid  as  possible.  It  is  only  when  the  secretion  is  glairy 
and  viscid  that  the  cough  is  so  tight.  We  have  an  illustration  in 
hemoptysis  of  how  easily  the  bronchial  tubes  may  be  cleared  of  purely 
fluid  contents,  for  then  the  blood  is  often  raised  so  readily  that  the 


3l6  CLINICAL  MEDICINE 

patients  are  not  sure  whether  it  comes  from  the  bronchial  tubes  or  from 
the  throat.  The  indication,  therefore,  for  the  treatment  of  the  cough 
of  bronchitis  is  to  give  medicines  which  promote  the  free  flow  of  the 
secretions,  combined  with  nervines  which  allay  the  spasm.  For  the 
first  indication  more  or  less  nauseant  expectorants  are  often  prescribed, 
such  as  ipecacuanha  and  syrup  of  squills.  Preparations  of  ammo- 
nia, especially  the  chlorid,  are  often  prescribed  to  promote  expectora- 
tion. Tartar  emetic  is  not  often  given  at  present  on  account  of  its 
depressing  effects,  except  in  the  manner  above  mentioned  during  the 
dry  acute  stage.  The  real  remedies,  however,  are  oils,  of  which,  as  we 
have  mentioned,  linseed  oil  is  the  best,  given  in  the  following  formulas: 

Lestogen  (Plain) 

Irish  moss i  ounce; 

Marshmallow  root 2  ounces; 

Aqua 3  pints. 

Boiled  one-half  hour;  strain  to  3  pints. 

Add  linseed  oil  (15  ounces)  to  make  emulsion. 

Oil  of  wintergreen 2  drams; 

Oil  of  cassia 2  drams; 

Glycerin 5  ounces; 

Simple  syrup 10  ounces; 

Dilute  hydrocyanic  acid 160  minims    (i    minim    to 

each  tablespoonf ul) . 
LiNOGEN  (Compound) 

Irish  moss i  ounce; 

Marshmallow  root 2  ounces; 

Aqua 3  pints. 

Boiled  one-half  hour;  strain  to  3  pints. 

Add  linseed  oil  (15  ounces)  to  make  emulsion. 

Oil  of  wintergreen 2  drams; 

Oil  of  cassia 2  drams; 

Glycerin 5  otmces; 

Simple  syrup 10  ounces; 

Dilute  hydrocyanic  acid 160  minims    (i    minim    to 

each  tablespoonf  ul) ; 

Chloral  hydrate 15  grains; 

Magendie's  solution 5  minims  to  each  ounce. 

I  have  rarely  found  an  attack  of  acute  bronchitis  which  is  not 
relieved  within  forty-eight  hours  by  this  remedy. 

We  would  now  refer  to  the  mechanical  effects  of  the  presence  of 
secretion  in  the  bronchial  tubes.  No  secretion  of  any  kind  should  be 
allowed  to  remain  in  them,  for  their  natural  function  is  to  contain 
nothing  but  air.  Hence,  for  purely  mechanical  reasons,  the  continu- 
ance of  bronchial  secretions  in  the  air-tubes  may  be  the  cause  of  death. 
This,  as  we  have  explained  in  our  first  chapter,  is  the  great  peril  of 
bronchitis  in  infants,  on  account  of  their  very  feeble  powers  of  expecto- 


FIBRINOUS    BRONCHITIS  3x7 

ration;  also  for  the  same  reason  in  bronchitis  of  the  aged.  We  need  not, 
therefore,  repeat  what  we  have  said  on  this  subject  in  the  first  chap- 
ter, and  pass  on  to  chronic  bronchitis. 

This  affection  commonly  results  from  neglect  to  cure  acute  bron- 
chitis, attacks  of  which  recur  again  and  again,  until  it  becomes  a  settled 
disease.  The  primary  origin,  however,  of  bronchitis  from  the  skin  is 
frequently  illustrated  in  these  patients  by  their  improvement  during 
the  hot  summer  months.  Gradually,  however,  the  freedom  from  the 
attacks  in  summer  grows  shorter  until  the  disease  becomes  settled  by 
the  operation  of  causes  which  constitute  a  vicious  circle,  because  the 
constant  coughing  in  time  produces  that  overdistention  of  the  air- 
vesicles  which  is  termed  "emphysema." 

For  every  case  of  chronic  bronchitis,  therefore,  special  measures 
should  be  taken  for  protection  of  the  skin,  for  which  there  is  nothing 
better  than  a  suit  of  perforated  chamois  skin  for  both  the  upper  and 
lower  extremities.  A  Hght  underwear  of  canton  flannel  should  be  put 
on  first,  while  the  chamois  skin  is  to  be  worn  only  in  the  daytime,  but 
not  at  night.  At  night  the  head  should  be  protected  by  something  light 
like  a  flannel  shawl,  whose  ends  are  pinned  under  the  chin,  while  the 
rest  of  the  shawl  drops  over  the  nape  of  the  neck.  The  principal 
importance  of  these  details  is  shown  by  the  frequency  with  which  colds 
are  contracted  at  night  in  bed  rather  than  while  one  is  going  about  in 
the  daytime,  and  the  •  old-fashioned  night  cap  which  our  ancestors 
wore  has  much  to  recommend  it. 

Emphysema,  in  turn,  greatly  interferes  with  the  free  circulation 
of  the  blood  in  the  lungs,  entaihng  dilatation  and  weakness  of  the 
right  cavities  of  the  heart.  This  necessarily  leads  to  passive  congestion 
of  the  lungs,  particularly  at  their  bases,  finally  establishing  a  condition 
in  which  more  cough  causes  more  pulmonary  weakness,  and  thus  the 
congestion,  which  leads  to  continuous  secretion  in  the  bronchial  tubes, 
must  be  coughed  up.  In  the  bronchitis  of  the  aged,  therefore,  we  often 
meet  with  excessive  secretion,  when  the  indication  is  to  directly 
diminish  the  bronchorrhea.  For  this  purpose  nitric  acid  combined 
with  moderate  doses  of  tincture  of  belladonna  may  be  used,  while  the 
heart  is  to  be  strengthened  by  full  doses  of  tincture  of  chlorid  of  iron 
with  nux  vomica. 

FIBRINOUS  BRONCHITIS 

This  affection  is  strange,  in  that,  unlike  bronchitis,  it  is  limited  in 
its  extent  to  only  a  single,  but  moderately  sized,  bronchus,  with  its 
branches.     There  is  no  accounting  for  it,  because  if  it  were  anything 


3l8  CLINICAL  MEDICINE 

like  a  general  affection  of  the  bronchi,  we  might  at  any  time  be  suf- 
focated by  its  occurrence.  It  is  characterized  by  the  formation  of 
exudations  in  the  affected  bronchus,  which  are  mistakenly  called 
fibrinous  casts,  for,  instead  of  being  fibrinous,  the  casts  are  really  com- 
posed of  membranous  mucin.  It  is  a  rare  affection,  for  I  have  seen 
only  2  cases  of  it,  but  they  were  typical,  consisting  of  white  casts,  not 
dissimilar  from  those  which  are  coughed  up  when  diphtheria  extends 
its  membranous  exudation  into  the  bronchi.  It  is,  however,  totally 
different  from  diphtheria,  both  in  its  antecedents  and  its  consequences. 

Ordinarily  it  sets  in  suddenly,  with  an  attack  of  severe  coughing 
and  dyspnea  which  continues  until  the  cast  is  expectorated,  when  it 
may  be  found  to  consist  of  a  perfect  membrane  which  had  lined  the 
bronchial  tube. 

It  may  occur  in  an  acute  form  during  the  course  of  typhoid  fever, 
or  even  in  croupous  pneumonia,  when,  however,  the  casts  are  not  long. 
Occasionally  it  occurs  in  the  course  of  pulmonary  phthisis,  but  in 
'  neither  of  these  affections  has  it  anything  hke  the  length  or  extent  of 
what  we  must  still  call  the  idiopathic  form.  In  some  patients  the 
attacks  may  occur  at  intervals  for  years,  but  are  not  at  all  like  the  fatal 
forms  coming  on  during  the  specific  fevers. 

Physical  examination  of  the  lung  shows  no  signs  of  extensive  bron- 
chitis, the  findings  being  locaKzed  in  the  affected  bronchus  itself,  where 
there  may  be  an  area  of  suppressed  breathing,  with  perhaps  a  few 
rales,  caused  by  a  single  piece  of  the  exudation  vibrating  in  the  current 
of  air  of  the  tube  to  which  it  is  attached.  Otherwise  there  seems  to 
be  suppressed  breathing  in  the  neighborhood. 

As  to  treatment,  the  inhalation  of  steam  from  vaporized  lime-water, 
combined  with  emetics,  is  the  most  successful. 

BRONCHOPNEUMONIA 

This  fatal  disease  is  responsible  for  the  great  mortality  in  cold  and 
temperate  climates,  following  measles  and  whooping-cough  in  children, 
so  that  nowadays,  instead  of  the  term  "capillary  bronchitis,"  a  more 
accurate  name,  "bronchopneumonia,"  is  given  to  this  affection.  We 
have  already,  in  our  chapter  on  "Catching  Cold,"  spoken  of  the  dis- 
astrous results  to  pulmonary  texture  of  the  processes  which  occur  in 
bronchopneumonia.  Instead  of  the  complete  absorption  of  the  exuda- 
tion into  the  air-vesicles  of  croupous  pneumonia,  the  exudation  into 
the  vesicles  in  bronchopneumonia  soon  involves  the  walls  of  the  vesicles, 
and  extends  into  the  interlobular  tissue,  simply  because  we  have 
conditions  exactly  simulating  the  ruinous  textural  changes  that  occur 


BRONCHOPNEUMONIA  319 

throughout  a  whole  lobe  of  a  lung  whose  main  bronchus  has  been 
plugged  by  the  accidental  lodgment  of  a  foreign  body. 

In  addition  to  the  exudation  into  the  air-vesicles  of  mucopus,  the 
lung  presents,  on  its  surface,  numerous  httle  depressions,  which  are 
due  to  collapse  of  tiie  air-vesicles,  by  a  mechanism  which  we  have 
already  described,  and  finally  the  extensive  injury  to  lung  tissue 
allows  all  sorts  of  bacterial  invasions  to  occur,  in  the  later  stages  in- 
cluding that  of  tuberculosis  itself.  Bronchopneumonia,  therefore, 
from  its  origin  in  bronchitis,  is  a  bilateral  affection,  and  far  more 
common  in  children  than  in  adults,  whose  secretions  in  bronchitis  are 
readily  expectorated. 

Symptoms. — The  first  clinical  sign  to  make  its  appearance,  which 
should  always  be  of  serious  import,  is  a  sudden  rise  in  temperature,  for 
that  means  the  supervention  of  pneumonia  upon  bronchitis.  The 
physical  signs  are  very  uncertain,  consisting  of  scattered  areas  of  dul- 
ness  on  percussion,  contiguous  with  the  Hmited  areas  of  a  clear  per- 
cussion, while  analogous  phenomena  appear  on  auscultation,  in  small 
areas,  of  harsh  bronchial  breathing,  with  fine  sibilant  rales  occurring 
immediately  adjacent  to  the  areas  of  suppression. 

Treatment. — In  infants  we  have  only  one  measure  which  we  can 
substitute  for  the  deficient  powers  of  expectoration,  and  that  is 
emetics.  As  the  action  of  emetics  here  is  purely  mechanical,  nauseant 
emetics  are  contra-indicated,  and  a  full  dose  of  5  gr.  of  the  sulphate  of 
zinc,  or  a  desertspoonful  of  the  wine  of  ipecac,  should  be  given.  The 
patient  should  not  be  left  lying  in  bed,  but  should  be  raised,  so  that  the 
head  hangs  down  as  soon  as  the  child  tries  to  vomit.  The  fingers, 
also,  should  be  introduced  into  the  mouth,  so  as  to  take  hold  of  the 
long  strings  of  expectoration,  and  thus  mechanically  assist  the  process 
of  getting  rid  of  mucus.  It  is  often  surprising  how  effective  these 
measures  appear  to  be,  and  the  patient,  who  is  on  the  verge  of  suffoca- 
tion, commences  to  breathe  freely  after  having  got  rid  of  the  tough 
accumulations  in  its  trachea.  As  soon  as  the  stomach  is  quiet  the  in- 
fant should  be  made  to  swallow  teaspoonful  doses  of  hot  milk  and 
Kme-water,  given  every  five  minutes  or  oftener,  on  account  of  the 
intimate  association  between  the  acts  of  swallowing,  and  the  beat  of 
the  heart,  brilhantly  demonstrated  by  Kroenacker,  who  showed  that 
every  act  of  swallowing  stimulates  the  cardiac  systole.  Even  in 
adults  the  swallowing  of  hot  drinks  often  promotes  the  expectoration, 
sipping  a  cup  of  hot  coffee  proving  very  efficacious  for  this  purpose  in 
the  morning  expectoration  of  phthisical  patients.  I  believe  that  I 
once  saved  the  life  of  an  infant  by  sitting  up  with  it  through  the  night. 


320  CLINICAL  MEDICINE 

and  administering  every  few  minutes  a  teaspoonful  of  hot  milk  and 
lime-water.  Meanwhile  the  skin  of  the  chest  should  be  stimulated  by 
rubbing  it  before  and  behind  with  hot  camphorated  oil,  while  in  all 
cases  showing  increasing  weakness  of  the  heart,  strychnin  or  nux  vomica 
should  be  used  along  with  3  to  5  gr.  of  camphor,  in  sterihzed  almond  oil, 
injected  hypodermically  in  the  loose  skin  of  the  abdomen.  Between 
times  the  whole  chest  and  abdomen  should  be  wrapped  loosely,  either 
with  flannel  or  with  cotton  batting.  All  oily  expectorants  should  be 
avoided,  and  the  bowels  emptied,  not  by  castor  oil,  but  by  doses  of 
calomel,  iV  to  ^  gr.  hourly,  which,  after  six  such  doses,  is  to  be  assisted 
by  a  full  enema  of  hot  normal  saline,  at  the  temperature  of  120°  F., 
to  make  it  a  heart  stimulant.  The  use  of  ammonia,  in  any  form,  as  an 
expectorant  is  contra-indicated  from  its  disagreeable  taste  to  these  little 
patients,  when  we  have  so  much  better  expectorants  in  the  agents 
already  mentioned. 

BRONCHIECTASIS 

General  dilatation  of  the  bronchi  is  sometimes  met  as  a  congenital 
defect,  but  local  dilatation  is  common  whenever  the  tissue  surrounding 
the  bronchi  is  consoHdated,  so  that  it  pulls  upon  the  air-tubes  and  thus 
assists  the  mechanical  dilatation  caused  by  intrabronchial  compres- 
sion of  the  air  in  the  act  of  coughing.  We  find  it,  therefore,  postmortem 
at  the  apex,  in  areas  which  have  been  consolidated  by  tuberculosis. 
Such  dilatation,  however,  is  not  easily  diagnosed  during  life. 

It  is  quite  otherwise  in  portions  of  the  lung,  especially  those  about 
the  base,  which  are  more  movable  during  the  acts  of  breathing,  when 
these  regions  are  more  or  less  fettered  by  extensive  pleuritic  adhesions. 
The  walls  of  the  bronchi,  already  weakened  by  prolonged  coughing  to 
get  rid  of  the  tenacious  mucus,  become  dilated,  usually  in  one  of  two 
ways,  if  not  in  both.  One  way  dilates  a  bronchus  into  a  fusiform  tube 
of  wide  diameter,  often  wider  than  any  of  the  main  bronchi.  In  an- 
other form,  whose  situation  is  usually  quite  at  the  base  of  the  lung,  the 
dilatation  is  saccular,  which  may  contain  as  much  fluid  as  an  old  vom- 
ica. In  the  walls  of  this  cavity  both  the  muscular  and  elastic  tissues 
disappear,  and  the  inner  hning  of  the  cavity  may  be  quite  smooth. 
One  striking  peculiarity  of  this  secretion  we  have  already  referred  to, 
namely,  that  it  becomes  horribly  fetid  and  may  accumulate  in  large 
quantities  through  the  night  or  day,  until  the  patient  bends  down, 
whereupon  the  fluid  becomes  emptied  into  a  main  bronchus,  and  then 
is  expectorated,  with  all  its  dreadful  fetor.  As  we  have  remarked 
before,  it  is  curious  that  these  patients  may  continue  to  secrete  and  to 


GANGRENE   OF   THE   LUNG  32 1 

expectorate  these  fetid  accumulations  without  the  general  health 
being  in  the  least  affected.  The  diagnosis  of  these  large  bronchiectatic 
cavities  is  usually  easy,  but,  so  far,  their  treatment  is  very  unsatisfac- 
tory; the  only  remedy  which  holds  out  any  prospect  of  a  curative  disin- 
fection being  a  frequent  and  prolonged  inhalation  of  the  terebene 
ozone  vapor  of  Dr.  Bertram  Waters,  of  New  York. 

GANGRENE  OF  THE   LUNG 

This  complaint  occurs  from  so  many  different  causes  that  it  may 
hardly  be  called  a  specific  disease.  In  many  cases  no  certain  cause 
can  be  determined.  In  my  experience  the  most  frequent  ante- 
cedent is  some  form  of  diabetes.  A  patient  in  the  Roosevelt  Hospital 
was  admitted  for  general  weakness  and  profuse  diabetes  insipidus,  as 
he  passed  no  oz.  of  Umpid  urine  in  the  day,  much  more  than  could 
possibly  be  accounted  for  by  what  he  ate  or  drank.  Suddenly  the 
diabetes  ceased,  to  be  immediately  succeeded  by  extensive  gangrene 
of  one  lung,  from  which  he  succumbed  in  thirty-six  hours.  The  only 
case  of  recovery  from  pulmonary  gangrene  that  I  have  met  was  in  a 
case  of  diabetes  mellitus,  to  be  mentioned  presently.  Gangrene 
sometimes  occurs  as  a  sequel  in  intense  lobar  pneumonia  at  the  base, 
but  these  patients  are  usually  in  a  weakened  state  of  health  when  the 
pneumonia  is  contracted.  It  may  occur  also  in  the  areas  supplied  by 
a  branch  of  the  pulmonary  artery,  which  has  been  occluded  by  an  em- 
bolus. In  the  majority  of  cases,  however,  no  particular  cause  can  be 
given  for  gangrenous  processes. 

The  symptoms  of  pulmonary  gangrene  are  usually  unmistakable, 
consisting  of  abundant  expectoration  of  a  very  fetid  character,  and  in 
the  expectorated  materials  many  fragments  of  lung  tissue  with  elas- 
tic fibers  are  to  be  found. 

Treatment.^The  only  treatment  for  pulmonary  as  well  as  for 
other  forms  of  gangrene  is  by  powdered  opium,  which  should  be  ad- 
ministered in  large  enough  doses  to  produce  the  physiologic  symptoms 
of  the  drug,  namely,  contraction  of  the  pupils  and  decreased  frequency 
of. the  respiration.  In  one  of  my  hospital  patients  who  had  very  ex- 
tensive gangrene  of  the  back  and  the  buttocks,  following  maUgnant 
purpura,  76  gr.  of  opium  a  day  were  administered  before  his  pupils 
became  affected,  but  when  they  did,  the  gangrenous  process  everywhere 
stopped.  In  one  case  which  I  saw,  where  all  the  symptoms  of  pulmo- 
nary gangrene  occurred  in  a  diabetic,  the  patient  recovered  under 
similar  doses  of  opium,  to  succumb  more  than  a  year  later  to  his  original 
diabetic  disease. 
21 


322  CLINICAL   MEDICINE 

PLEURITIS    (PLEURISY) 

Pleurisy  may  begin  with  shivering,  but  not  with  the  distinct  rigor, 
as  in  the  case  of  pneumonia.  The  two  great  serous  membranes,  the 
peritoneum  and  the  pleura,  fully  illustrate  the  appHcations  of  the 
principles  of  our  first  chapter,  that  of  the  mechanism  of  "catching  cold." 
Nothing  is  a  more  common  antecedent  of  an  attack  of  pleurisy  than  a 
local  chill  of  the  skin.  As  we  explained  in  that  chapter,  one  of  the 
laws  of  vasomotor  association  is  that  the  vasomotor  nerves  of  the  skin 
are  always  in  relation  with  the  same  class  of  nerves  supplying  the  tis- 
sues or  organs  underneath  that  cutaneous  area.  The  first  effect  of 
cold  is  to  contract  the  arteries  of  a  part,  and  thus  deprive  that  par- 
ticular region  of  its  normal  supply  of  arterial  blood;  but  just  this  effect 
is  brought  about  by  reflex  action  in  the  circulation  of  parts  under- 
neath, causing  first  arterial  anemia,  and  hence  damage  to  the  tissue 
cells,  to  be  followed  by  inflammatory  reaction.  This  is  illustrated 
frequently  in  the  clinical  accompaniments  of  pleurisy,  which  begin  as 
a  local  inflammation  of  the  pleura.  It  may  also  be  remembered  that 
we  stated  that  this  initial  lesion  prepares  the  way  for  microbic  inva- 
sions of  various  kinds  of  the  affected  tissues.  It  is  rather  difficult 
to  account  for  the  invasion  of  the  pleura  by  tubercle  bacilli  more  com- 
monly than  by  any  other  micro-organism.  So  frequently  is  this  the 
case  that  probably  over  90  per  cent,  of  the  attacks  of  pleurisy  are 
tuberculous.  This  may  not  be  easy  to  demonstrate  at  first  in  all 
cases,  but  in  pleurisies  accompanied  by  effusion  the  injection  of  the 
effusion  into  susceptible  animals,  Hke  guinea-pigs,  will  then  demon- 
strate the  presence  of  tuberculosis  without  mistake.  In  men,  after 
an  attack  of  pleurisy  with  effusion,  some  may  recover  completely,  but 
the  rule  is  that  in  after  years,  sometifmes  five  or  ten  years,  these 
patients  will  develop  phthisis.  Even  in  some  who  apparently  recover 
perfectly,  the  postmortem  statistics  of  autopsies,  both  in  Europe  and 
in  America,  show  such  a  number  of  chronic  pleuritic  adhesions,  pre- 
sumably of  tuberculous  origin,  that  we  must  admit  that  the  pleurae  have 
a  special  tendency  to  develop  tuberculosis  far  more  than  the  peri- 
toneum. This  may  be  due  to  the  fact  that  the  tissues  of  the  pleura 
are  unresting,  so  that  its  two  surfaces  rub  against  one  another  from 
18  to  24  times  a  minute.  The  presence  of  pneumococci,  however,  in 
the  effusion  is  not  of  unfavorable  import.  Quite  otherwise  is  it  with 
a  pleuritic  effusion  showing  quantities  of  streptococci,  because  this  or- 
ganism causes  a  much  more  serious  and  prolonged  inflammation.  The 
bacterial  examinations,  therefore,  of  pleuritic  effusion  ought  to  be 
made  whenever  practicable.     Other  micro-organisms  are  also  to  be 


PLEURITIS    (pleurisy)  323 

found  in  pleuritic  effusions,  though  much  less  frequently  than  those 
we  have  mentioned. 

Symptoms. — Clinically,  the  first  sign  of  pleurisy  is  cough.  As  we 
have  described  in  our  chapter  on  Cough,  where  the  pleuritis  is  limited 
and  fibrinous,  the  cough  is  short  and  hacking,  constituting  the  omin- 
ous hacking  cough  of  the  first  stages  of  phthisis.  As  the  inflammatory 
area  extends,  the  exudation  becomes  more  liquid  or  serofibrinous,  the 
cough  in  the  first  stages  being  more  severe  if  the  exudation  becomes 
more  liquid,  and  serous  as  well  as  more  abundant.  The  composition 
of  this  effusion  closely  resembles  that  of  the  liquor  sanguinis,  and  if  it 
becomes  abundant,  the  cough  at  first  subsides,  because  the  two  irri- 
tated surfaces  of  the  pleura  are  separated  from  each  other  by  the 
effusion.  When,  however,  the  effusion  is  absorbed  the  two  inflamed 
surfaces  come  together  again,  whereupon,  as  we  have  before  explained, 
the  cough  may  become  more  violent,  and  is  best  treated  by  strapping 
the  side.  Another  early  symptom  of  extensive  pleurisy  is  pain,  which 
is  of  a  stabbing  character,  indicated  by  the  gesture  of  the  patient  with 
the  tips  of  the  fingers  as  before  described.  This  pain  is  commonly 
accompanied,  as  we  should  expect,  by  an  external  tenderness  and 
pressure. 

A  false  dyspnea  develops,  which  is  not  due  to  embarrassment  either 
in  the  bronchi  or  in  the  air-vesicles,  but  wholly  to  the  pain  which  the 
movements  of  the  ribs  and  pleura  produce,  the  breathing  being  very 
short  and  hurried.  This  pain  should  be  easily  distinguished  from  the 
pain  in  pleurodynia,  due  to  mflanunation  of  the  intercostal  nerves.  I 
have  often  known  this  pain  of  pleurodynia  to  be  mistaken  for  that  of 
pleurisy,  and  so  treated;  but  pleurodynia  is  not  accompanied  with 
cough,  while  pleurisy  always  is.  Another  symptom  of  pleurisy  is 
fever.  This  ordinarily  does  not  reach  the  degree  of  pneumonia,  as 
its  range  is  between  101°  and  103°  F.  Pleurisy  being  a  local  disease, 
when  at  all  extensive,  the  temperature  on  the  affected  side  is  higher 
than  on  the  other  side. 

In  pleuridc  effusions  there  is  nothing  so  misleading  as  variations 
in  the  vocal  resonance.  Usually,  at  first,  the  vocal  resonance  is  dimin- 
ished, but  instead  we  may  have  it  greatly  intensified,  even  more 
than  in  pneumonia,  so  as  to  constitute  true  bronchophony.  Some- 
times in  this  condition  it  has  a  curious  squeaking  character,  termed 
by  Laennec,  ''egophony,"  from  its  supposed  resemblance  to  the 
blearing  of  a  goat,  usually  most  evident  at  the  angle  of  the  scapula. 

The  seat  of  the  pain  is  usually  lateral  or  even  under  the  scapula, 
where  the  ribs  move  most  freely.     At  an  early  stage  palpation  may 


324  CLINICAL  MEDICINE 

give  a  sensation  of  rubbing,  under  the  tip  of  the  finger,  but  it  is  by 
auscultation  that  the  most  decisive  signs  are  revealed,  and  directly 
under  the  inflamed  area  a  to-and-fro  rubbing  friction  sound  is  per- 
ceptible. This  sound  may  first  be  heard  only  at  the  end  of  a  full  in- 
spiration, but  it  quickly  becomes  double  and  is  very  superficial,  thus 
distinguishing  it  from  the  fine  crackle  in  cases  of  bronchitis.  It  differs 
from  bronchitis,  however,  in  that  it  is  not  modified  by  coughing,  and 
also  differs  from  the  fine  crackle  of  pneumonia  in  that  it  occurs  on  both 
inspiration  and  expiration,  while  the  rale  of  pneumonia  occurs  only 
on  inspiration,  and  is  followed  by  clear  expiration.  While  extensive 
pleurisy  may  be  accompanied  with  some  secretion  of  the  viscid  mucus 
in  the  bronchi,  it  may  be  said  that  bronchitis,  as  such,  is  not  a  common 
accompaniment  of  pleurisy,  the  expectoration  not  being  bloody,  but 
rather  viscid  in  character. 

Effusion  in  pleurisy  varies  greatly  in  amount  in  different  cases, 
but  if  at  all  abundant  it  produces  very  characteristic  effects,  which,  it 
should  be  remembered,  are  always  of  a  mechanical  nature.  When  it  is 
Hmited  to  the  lower  regions  of  the  chest,  it  produces  more  or  less  col- 
lapse at  the  base  of  the  lung,  with  weakening  of  the  respiratory  mur- 
murs, which  sound  distant  and  muffled.  Both  tactile  and  vocal  fremitus 
may  be  diminished  or  even  abolished.  As  we  have  said,  the  effusion 
may  become  so  abundant  that  it  fills  the  whole  cavity  of  the  chest  on 
that  side,  extending  all  the  way  up  to  the  clavicle.  If  this  effusion  has 
occurred  slowly,  the  patient  may  be  quite  unaware  of  its  amount,  the 
only  symptom  being  increased  shortness  of  breath  on  exertion.  In 
pleurisy  the  respiratory  zone  of  the  face  should  be  observed  so  long  as 
the  effusion  is  limited,  the  nostril  on  the  affected  side  being  actively 
dilated.  When,  however,  the  effusion  wholly  fills  that  side,  so  that  no 
air  enters  that  lung,  the  nostril  on  the  affected  side  collapses;  while 
on  the  sound  side  it  is  actively  dilated,  in  which  case  the  air  is  driven 
out  of  the  lung  entirely,  and  the  lung  is  pressed  against  the  spinal  col- 
umn, and  if  it  continues  there  for  some  time  the  lung  is  said  to  be  car- 
nified.  The  whole  chest  on  that  side  bulges  in  comparison  with  the 
opposite  side,  and  the  intercostal  spaces  are  obliterated  and  the  res- 
piratory movements  abolished.  Previous  to  this  extreme  degree  of 
effusion,  when  it  is  level  it  does  not  reach  the  fifth  interspace,  the  heart 
becomes  displaced,  with  a  change  in  the  situation  of  the  apex-beat. 
But  the  whole  organ  is  pushed  over,  in  left-sided  pleurisy,  to  the  right, 
so  that  the  heart-sounds  are  clearer  directly  under  the  manubrium 
or  along  its  right  side,  the  right  ventricle  being  directly  behind 
the  sternum.     In  right-sided  pleurisy,  with  effusion,  the  heart  may 


PLEURITIS    (pleurisy)  325 

be  dislocated  to  the  left,  and  the  heart-sounds  be  clearest  in  the 
axilla. 

With  the  accumulation  of  fluid,  the  percussion  resonance  gradu- 
ally diminishes  until  it  may  end  in  absolute  flatness.  We  can  thus 
estimate  progressive  increase  of  the  effusion  from  day  to  day.  When 
the  effusion  rises  above  the  fourth  rib  in  front,  a  tympanitic  note, 
called  Skoda's  resonance,  develops  directly  under  the  clavicle.  The 
percussion  resonance  has  a  resisting,  wooden  quahty,  different  from  the 
dulness  of  pneumonia.  When  the  patient  is  in  the  erect  posture  the 
upper  line  .of  dulness  is  not  horizontal,  but  higher  behind  than  it  is  in 
front.  With  medium-sized  effusions  this  Hne  begins  lowest  behind,  and 
then  it  advances  upward  and  forward  in  a  letter  "s"  curve  to  the  axillary 
region,  whence  it  proceeds  in  a  straight  Hne  to  the  sternum.  There  is 
also  a  small  area  of  from  2  to  5  cm.  of  dulness  along  the  spine  on  the 
side  opposite  the  pleurisy  with  the  apex  upward,  caused  by  bulging 
of  the  mediastinum  by  the  fluid.  On  the  right  side  the  dulness  passes 
without  change  into  that  of  the  Hver. 

Palpation. — One  of  the  most  valuable  signs  of  the  effusion,  when  it 
does  not  reach  above  the  fourth  rib,  is  by  carefully  noting  alterations 
in  the  vocal  fremitus.  This,  as  previously  mentioned,  is  aboHshed 
by  the  effusion,  but  if  the  patient  is  sitting  and  the  examiner  places 
the  tip  of  one  of  his  fingers  at  the  level  of  the  fluid  in  front,  and  simi- 
larly, a  finger  of  the  other  hand  at  the  same  level  behind,  when  the 
patient  leans  forward,  the  vocal  fremitus  disappears  from  where  it 
was  in  front,  and  reappears  from  where  it  was  absent  behind;  and  then, 
on  having  the  patient  He  down,  it  reappears  in  front  and  disappears 
behind. 

BaccelH  claims  that  the  whispered  voice  is  transmitted  through  a 
serous,  but  not  through  a  purulent,  effusion. 

The  lung,  however,  with  its  pleural  covering  does  not  hang  in  the 
chest  like  a  body  suspended  in  a  bottle,  but,  owing  to  the  presence  of 
the  heart  and  the  great  blood-vessels,  an  accumulation  of  fluid  in 
the  pleura  follows  a  pecuHar  arrangement,  which  it  is  important  to 
know  when  paracentesis  is  to  be  resorted  to. 

The  duration  of  pleurisy  is  very  unHke  that  of  pneumonia,  in  that 
it  does  not  terminate  in  crisis,  but  may  last  for  days  and  weeks,  as  will 
be  noted  further  on. 

Treatment. — So  long  as  the  pleurisy  is  locaHzed,  as  it  so  often  is, 
with  beginning  tuberculosis,  it  may  be  safely  left  alone.  Should 
the  subjective  symptoms,  such  as  pain  and  the  auscultatory  symptoms, 
persist  for  some  time,  local  bHsters  are  of  great  value,  but  they  should 


326  CLINICAL  MEDICINE 

never  be  applied  in  the  acute  stage  any  more  than  in  other  acute  con- 
ditions. On  the  other  hand,  the  rubbing  into  the  part  of  blue  ointment 
of  mercury  is  of  unmistakable  advantage.  When  the  sign  of  accumu- 
lation of  fluid  effusion  has  developed,  no  time  should  be  lost  to  discover 
its  nature  by  puncture  with  a  hypodermic  needle,  when  if  the  effusion 
proves  to  be  purulent,  no  time  should  be  lost  to  evacuate  it.  Certain 
facts,  however,  should  now  be  borne  in  mind  if  the  effusion  proves  to 
be  serofibrinous.  The  tendency  of  all  such  effusions  is  to  press  out  the 
air  from  the  lungs.  If  this,  as  is  commonly  the  case,  should  be  at  the 
base,  the  portion  of  the  lung  becomes  more  or  less  solidified  by  com- 
pression, and  then  begins  that  frequent  final  result  of  pleuritic  effusion, 
namely,  the  affected  parts  of  the  lung  become  fettered  by  fibrinous 
bands.  In  extensive  effusions  these  fibrinous  bands  or  adhesions  may 
in  time  make  it  impossible  for  the  collapsed  lung  tissue  to  expand  again, 
and  when  the  effusion  fills  the  whole  side  of  the  chest,  the  lung,  as 
heretofore  described,  becomes  changed  into  an  airless  viscus  lying 
against  the  spinal  column.  It  is  this  fettering  of  pulmonary  tissue 
which  so  urgently  calls  for  early  removal  of  the  effusion  by  aspiration, 
so  that  the  lung  may  be  expanded  again  before  it  is  tied  down  by  adhe- 
sions. The  favorable  results  of  early  aspiration  or  early  removal  of 
the  liquid  prove  that  this  measure  is  often  too  long  delayed,  because 
when  performed  early  its  risks  are  very  sKght.  This  is  not  at  all  the 
case  when  the  effusion  has  been  allowed  to  accumulate  and  remain 
for  a  number  of  weeks.  When  it  reaches  above  the  fourth  rib  to  the 
clavicle,  a  number  of  serious  dangers  may  occur  during  the  operation 
of  removing  the  fluid.  It  should  be  remembered  that  the  thorax  on 
both  sides  constitutes  a  pair  of  air-tight  boxes,  and  if  one  of  them  full  of 
fluid  is  too  rapidly  withdrawn,  there  must,  on  mechanical  principles,  be 
a  powerful  suction  on  both  the  pleural  walls  and  on  the  fettered  lungs. 
Hemorrhage,  therefore,  or  true  tearing  of  the  lung  substance  may  follow, 
but  along  with  this  the  other  lung  has  an  intense  strain  thrown  upon  it, 
which  leads  to  rapid  bronchial  effusion,  which  is  often  bloody  as  well 
as  accompanied  by  general  edema  of  its  substance.  Sudden  death, 
therefore,  may  follow  too  rapid  withdrawal  of  chronic  effusions,  as  I 
have  known  in  several  instances.  Therefore,  I  always  enjoin  that  no 
more  than  10  oz.  at  a  time  should  be  withdrawn.  In  many  cases  this 
so  relieves  the  internal  tension  that  rapid  absorption  follows,  while 
all  the  fatal  accidents  just  mentioned  are  prevented. 

"The  operation  is  extremely  simple  and  is  practically  without  risk. 
The  spot  selected  for  puncture  should  be  either  in  the  sixth  intercostal 
space  in  the  midaxilla  or  at  the  outer  angle  of  the  scapula  in  the  eighth 


PNEUMOTHORAX    AND    HYDROPNEUMOTHORAX  327 

space.  The  arm  of  the  patient  should  be  brought  forward,  with  the 
hand  on  the  opposite  shoulder,  so  as  to  widen  the  spaces.  The  needle 
should  be  thrust  in  close  to  the  upper  margin  of  the  rib,  so  as  to  avoid  the 
intercostal  artery,  the  wounding  of  which,  however,  is  an  exceedingly- 
rare  accident.  The  fluid  should  be  withdrawn  slowly.  ...  In  chronic 
cases  of  serous  pleurisy,  after  the  failure  of  repeated  tappings,  S.  West 
has  shown  the  great  value  of  free  incision  and  drainage.  He  has  re- 
ported cases  of  recovery  after  effusions  of  fifteen  and  eighteen  months' 
standing.  Repeated  tappings  may  be  required  in  some  cases.  In  the 
chronic  cases  the  injection  of  adrenahn  solution  (20  to  30  drops  of 
a  I  :  1000  solution)  into  the  pleural  cavity,  after  aspiration,  has  proved 
of  value." 

Surgeons  are  learning  now  that  often  all  that  is  necessary  in  inter- 
nal accumulations  of  fluid  is  to  relieve  tension  by  moderate  withdrawal 
of  the  effusion,  leaving  nature  to  do  the  rest. 

Very  often,  particularly  in  tuberculous  cases,  a  great  deal  will  be 
effected  by  firmly  strapping  the  side  with  long  straps  of  adhesive 
plaster,  extending  from  the  spine  to  the  median  hne  in  front.  These 
should  always  be  applied  from  below  upward,  the  patient  taking  a  full 
inspiration  as  soon  as  the  straps  are  appHed  to  the  spine,  and  then 
letting  the  air  out  by  expiration  while  the  strap  is  brought  forward. 
The  next  strap  ought  to  be  appHed  over  one-half  the  width  of  the  pre- 
ceding strap,  care  being  taken  to  brace  the  lower  side  of  the  strap 
as  one  proceeds  upward,  so  that  the  whole  appHcation  shall  be  smooth 
and  not  wrinkeld.  I  use  this  procedure  very  commonly  in  advanced 
phthisis  over  large  cavities,  as  it  greatly  reduces  both  cough  and  ex- 
pectoration. 

There  is  one  and  not  an  infrequent  form  of  pleurisy  which  is 
benefited  by  medicines,  and  that  is  when  it  occurs  in  rheumatic  pa- 
tients. Here  the  free  administration  of  the  saUcylates  is  of  unquestion- 
able benefit. 

PNEUMOTHORAX  AND  HYDROPNEUMOTHORAX 

Pneumothorax,  or  an  accumulation  of  air  in  the  pleural  cavity, 
sometimes  occurs  without  any  Hquid  effusion,  which  a  description  of 
a  case  in  my  own  experience  will  fully  illustrate: 

A  lady  began  to  show  unmistakable  signs  of  a  tubercular  deposit 
at  the  apex  of  the  right  lung,  when  she  suddenly  was  attacked  with 
great  dyspnea.  Examination  showed  a  total  absence  of  any  breath- 
sounds  in  the  right  chest,  but  with  a  hyperresonant  percussion  over 
the  whole  lung.     The  explanation  of  this  condition  was  that  a  small 


328  CLINICAL  MEDICINE 

hole  had  been  formed  by  softening  of  the  tubercular  deposit,  which 
allowed  the  air  to  enter  the  pleural  cavity  until  the  lung  was  entirely 
collapsed,  and  pressed  against  the  spinal  column.  Why  such  an  acci- 
dent does  not  often  occur  is  due  to  pleuritic  adhesions  forming  over 
every  tubercular  focus,  but  in  her  case  such  protective  adhesions  were 
absent,  and  thus  allowed  the  entrance  of  air  into  that  side  of  the  chest, 
causing  pure  pneumothorax. 

The  great  dyspnea  characteristic  of  the  first  stage  of  pneumothorax 
is  due  to  the  other  lung  being  too  suddenly  called  upon  to  perform  the 
whole  duty  of  both  lungs.  Nothing  can  be  done  in  these  cases  except 
to  enjoin  absolute  quiet,  then  in  the  course  of  a  few  days  the  air  will 
be  all  reabsorbed  without  any  pleurisy  or  adhesions,  because,  as  we 
have  before  mentioned,  air  in  the  bronchi  and  air-vesicles  is  normally 
sterile. 

A  more  common  condition  is  termed  "hydropneumothorax,"  which 
occurs  in  the  course  of  pulmonary  phthisis,  after  the  formation  of  a 
more  or  less  large  cavity.  In  such  cases,  if  a  communication  between 
the  vomica  and  pleura  occurs,  there  will  be  both  an  accumulation  of 
fluid  and  of  air  in  the  pleural  cavity,  causing  what  is  called  hydro- 
pneumothorax,  a  condition  not  infrequently  present  in  the  terminal 
stages  of  pulmonary  phthisis. 

The  treatment  for  this  condition  is  the  same  as  that  before  pre- 
scribed for  the  original  disease  itself. 

CIRRHOSIS  OF  THE  LUNG 

Connective  tissue  is  always  ready  to  take  the  place  of  parenchy- 
matous tissue,  whenever  the  latter  becomes  devitalized  and  degener- 
ated. It  has  a  variety  of  names  applied  to  it,  according  to  the  tissue 
affected,  but  the  condition  itself  is  one  and  the  same  in  them  all.  In 
nervous  tissue  it  is  called  sclerosis;  in  glandular  organs,  such  as  the 
liver  and  kidneys,  it  is  called  cirrhosis ;  and  in  lung  tissue  it  is  mis- 
takenly called  interstitial  pneumonia,  whether  vesicular  or  interstitial, 
the  preferable  term  here  being  "fibrosis  of  the  lung." 

This  process  in  the  lung  may  be  either  local  or  general,  so  that  a 
whole  lung  may  be  shrunken  into  a  fibrinous  mass,  lying  closely  packed 
against  the  spinal  column.  The  manner  in  which  a  lung  becomes 
cirrhosed  differs  according  to  what  texture  of  the  lung  is  first  affected. 
The  process  may  begin  with  a  pleurisy,  which  presents  many  bands  or 
trabeculae  penetrating  the  lung  in  all  directions,  soon  obliterating  all 
traces  of  air-vesicles,  but  not  the  bronchi,  which,  instead,  may  be  di- 
lated.    Another  form  of  pulmonary  fibrosis  begins  in  the  peribronchial 


EMPHYSEMA  329 

tissue  of  the  finer  air-tubes,  and  from  there  invades  interlobular 
spaces,  with  hyperplasia  of  their  connective  tissue.  This  process  very 
frequently  starts  from  a  tuberculous  focus,  especially  at  the  apex. 
Where  the  process  is  limited  to  one  lung,  the  shrinkage  of  the  tissue 
causes  great  contraction  of  that  side,  with  displacement  of  the  heart, 
pushed  over  as  it  is  by  the  emphysematous  compensatory  enlargement 
of  the  opposite  lung.  In  many  cases  the  opposite  lung  is  also  tuber- 
culous, so  that  numerous  bacilh  may  be  found  in  the  expectoration. 
On  the  other  hand,  the  lung  originally  affected,  although  it  began  with 
tuberculosis,  its  fibrosis  obhterates  any  trace  of  the  original  infection, 
so  that  many  patients  with  fibrotic  phthisis  will  show  for  months  no 
tubercle  bacilli  in  the  sputum. 

Lung  fibrosis,  as  we  have  already  intimated,  may  be  partial  or 
general;  partial  when  it  is  connected  originally  with  some  localized 
affection,  such  as  bronchopneumonia.  When  general,  it  tends  to  be- 
come unilateral,  and  to  remain  so  for  many  years,  with  great  shrinkage 
of  the  side  and  corresponding  displacement  of  the  heart.  Not  only  are 
the  interstitial  spaces  obliterated,  but  the  ribs  may  even  overlap,  the 
shoulder  being  greatly  depressed,  and  the  vertebrae  displaced  toward 
the  affected  side.  With  all  this  the  patient  may  enjoy  a  fair  degree  of 
health  for  a  number  of  years,  but  always  with  more  or  less  cough  and 
bronchial  secretion.  Not  uncommonly  hemoptysis  sets  in  suddenly 
and  may  be  the  cause  of  the  patient's  death,  but  if  the  patient  walks 
on  a  level  and  does  not  tax  his  breathing  by  muscular  or  mental  effort 
he  may  continue  for  a  number  of  years  in  a  fair  state  of  health. 

The  treatment  of  such  cases  is  necessarily  limited  to  the  observa- 
tion of  hygienic  rules. 

EMPHYSEMA 

All  the  acts  of  coughing  have  a  tendency  to  dilate  the  air-vesicles 
by  a  mechanism  easily  understood.  Similarly,  compensatory  over- 
distention  occurs  in  the  air-vesicles  of  a  region  contiguous  to  any 
part  of  the  apparatus  of  breathing  which  for  the  time  has  its  respi- 
ratory function  in  abeyance.  Thus,  if  the  base  of  a  limg  is  compressed 
by  a  pleuritic  effusion,  the  air- vesicles  at  the  apex  become  overdis- 
tended  by  more  active  breathing.  Likewise,  if  one  lung  is  prevented 
from  breathing  from  any  cause,  the  opposite  lung  is  in  the  state  of 
compensatory  emphysema.  The  commonest  cause,  however,  of  per- 
manent emphysema  is  general  chronic  bronchitis  affecting  both  lungs, 
for  it  should  be  remembered  that  in  the  act  of  coughing  the  free  exit 
of  air  is  forcibly  interrupted  during  expiration,  and  the  longer  the 


330  CLINICAL   MEDICINE 

bronchitis  lasts,  the  more  certain  it  is  that  the  air-vesicles  will  become 
not  only  permanently  dilated,  but  may  be  ruptured  in  many  localities, 
so  as  to  constitute  simple  cavities.  The  effects  of  this  condition  are 
easily  expUcable  on  mechanical  grounds.  Large  tracts  of  air  space 
in  the  lungs  are  thus  no  longer  free  in  the  aeration  of  the  blood.  The 
whole  chest  becomes  altered  in  shape,  so  as  to  contrast,  in  every  way, 
with  the  shrunken  lung  tissue  of  phthisis.  The  movements  of  the  ribs 
also  are  altered,  so  that  in  place  of  the  anteroposterior  and  lateral 
movements  of  expansion,  the  chest  moves  mainly  up  and  down,  with 
very  little  expansion  in  other  directions.  The  work  of  the  accessory 
muscles  of  respiration,  which  are  attached  to  the  clavicles  and  to  the 
scapula,  is  so  increased  that  these  muscles  become  greatly  hypertro- 
phied,  while  the  chest  itself  becomes  barrel  shaped. 

The  changes  in  the  pulmonary  tissues  themselves  consist  in  very 
extensive  rupture  of  the  septa  between  the  air-vesicles  until  they 
may  form  cavities  of  varying  sizes  with  great  destruction  of  the  capil- 
laries on  the  walls  of  the  vesicles,  through  which  aeration  of  the  blood 
occurs.  This  necessarily  entails  increased  labor  on  the  part  of  the 
right  chambers  of  the  heart  from  dilatation  of  both  the  right  auricle 
and  the  right  ventricle,  leading  to  enlargement  of  the  veins  of  the 
neck  from  incompetence  of  the  tricuspid  valves,  and  in  extreme  cases 
of  prolonged  chronic  bronchitis  with  emphysema,  general  venous  stasis 
with  anasarca  may  result. 

One  pecuharity  of  emphysema  is  that  in  many  cases  it  is  un- 
doubtedly due  to  congenital  weakness  in  the  walls  of  the  air-vesicles, 
owing  to  the  absence  or  sufficient  development  of  the  elastic  fibers. 
One  evidence  of  this  is  its  frequent  occurrence  in  families,  so  that  it  is, 
unquestionably,  a  hereditary  affection.  These  cases  as  well  as  other 
instances  of  emphysema  are  often  cyanotic  to  a  degree  not  seen  in  any 
other  disease,  except  in  some  instances  of  congenital  heart  malforma- 
tion. The  cyanotic  emphysema  patients,  however,  may  be  able  to  go 
about  their  business  with  very  little  inconvenience,  except  from  active 
muscular  exercise.  As  may  be  naturally  inferred  from  its  common 
origin  in  chronic  bronchitis,  emphysematous  patients  are  apt  to 
catch  cold  from  slight  exposure,  because,  in  addition  to  the  bronchitis, 
they  are  subject  to  asthmatic  paroxysms. 

The  physical  signs  are  plain  enough  on  most  superficial  examina- 
tion. If  an  inspection  shows  dilated  veins  in  the  temples,  and  all  the 
way  down  in  the  course  of  the  jugulars  on  the  right  side  during  cough- 
ing, the  supraclavicular  bulb  frequently  dilates  into  a  tumor.  We 
have  already  mentioned  the  characteristic  barrel  shape  of  the  chest 


EMPYEMA 


331 


and  the  great  hypertrophy  of  the  muscles  attached  to  the  clavicles  and 
the  scapulae.  The  shoulders  are  high  and  rounded,  and  the  mouth  is 
never  closed,  the  nostrils  remaining  in  a  permanently  fixed  state  of 
dilatation.  Percussion  is  resonant  everywhere,  so  that  the  normally 
dull  areas  over  the  heart  are  no  longer  present,  the  emphysematous 
lung  completely  overlapping  the  heart,  as  it  is  more  Hkely  to  be  dilated 
at  the  anterior  borders  of  the  lung  than  elsewhere.  The  heart  impulse 
is  felt  only  in  the  epigastrium.  On  auscultation,  no  vesicular  murmur 
is  present,  but  instead  every  variety  of  cooing  or  harsh  bronchial  breath- 
ing sounds  are  heard,  produced  by  secretions  in  the  congested  bronchial 
tubes. 

The  treatment  of  the  disorders  of  emphysema  should  always  be 
causative;  in  other  words,  it  should  be  that  of  chronic  bronchitis. 
The  iodids  are  equally  indicated  here  as  in  that  affection,  and  some 
good  may  be  expected  from  arsenic  combined  with  remedies  for  con- 
ditions of  an  asthmatic  kind,  as  previously  described.  All  measures 
calculated  to  diminish  bronchitis  should  be  persevered  in  at  all  times. 
In  the  congenital  cases,  if  there  is  evidence  of  premature  hj'pertrophy 
and  calcification  of  the  upper  costal  cartilages,  Freund's  operation 
for  the  resection  might  be  tried. 

EMPYEMA 

This  means  lung  abscess,  and  is  occasioned  by  different  causes. 
It  is  much  more  common  in  children  than  in  adults,  particularly  after 
an  attack  of  pneumonia.  As  the  abscess  forms  in  an  organ  of  constant 
movement,  and  always  under  high  tension,  the  pus,  as  it  is  secreted,  may 
go  anywhere :  it  may  burst  into  a  bronchial  tube,  and  thus  form  a  bron- 
chial fistula,  or  it  may  appear  either  on  the  chest  wall  before  or  behind, 
or  it  may  take  a  downward  course  and  come  out  in  the  groin,  or  it  may 
perforate  the  diaphragm,  and  give  rise  to  subphrenic  abscess.  Usu- 
ally the  course  of  a  fistula  which  leads  to  its  original  source  can  be  easily 
made  out,  but  sometimes,  when  the  abscess  is  at  first  deeply  seated  in 
the  ung,  it  is  difficult  to  locate  it,  and  we  have  to  rely  upon  the  con- 
stitutional symptoms  of  septic  infection  to  guide  us,  the  patients  con- 
tinuing to  show  the  symptoms  of  serious  infection,  which  are  high  fever, 
with  characteristic  daily  rise  and  fall  of  the  temperature,  accompanied 
by  great  wasting  and  loss  of  strength.  Empyema,  therefore,  can 
never  be  regarded  as  a  trivial  complaint,  but  the  aim  should  always  be 
to  trace  it  to  its  source,  for  the  purpose  of  thorough  drainage.  In 
children  and  not  infrequently  in  adults  this  may  be  done  only  by  a 
partial  resection  of  one  or  more  ribs.     I  once  cured  a  patient  by  a 


332  CLINICAL  MEDICINE 

single  aspiration  of  the  pus.     This  procedure,  however,  should  not 
be  recommended. 

Empyema  also  occurs  as  a  sequel  to  many  specific  fevers,  especially 
scarlatina.  It  is,  therefore,  preeminently  a  surgical  affection  and,  as 
such,  need  not  be  further  considered  here. 

HICCUP 

This  is  a  spasmodic  affection  of  the  phrenic  nerve  which  may 
be  very  trivial  and  temporary,  but  at  other  times,  as  we  have  already 
mentioned,  in  the  course  of  chronic  interstitial  nephritis,  a  serious 
symptom,  not  at  all  amenable  to  ordinary  remedies.  It  is  particularly 
ominous  when  it  occurs  in  conjunction  with  abdominal  lesions,  such  as 
strangulated  hernia  or  peritonitis. 

The  best  treatment  for  this  troublesome  affection  is  by  teaspoon- 
ful  doses  of  the  spirits  of  chloroform  in  water,  every  two  or  three  hours, 
conjoined  with  hypodermics  of  -^  gr.  of  pilocarpin,  which  may  be  in- 
creased to  Y5  gr. 


CHAPTER    VI 

DISORDERS  OF  THE  ORGANS  OF  DIGESTION 

In  our  species  the  condition  of  digestion  of  food  differs  materially 
from  those  of  other  animals.  The  old  prophet  says  that  an  ass  knoweth 
his  master's  crib,  to  which  statement  we  may  add  that  the  reason  why 
that  animal  is  content  with  his  nutritious  but  unvarying  diet  is  simply 
because  he  is  an  ass,  while  it  would  take  a  widely  read  geographer  to 
correctly  state  whence  comes  every  article  found  on  an  ordinary 
mechanic's  table;  still  more  at  a  banquet,  as  the  air  above,  the  earth 
below,  and  the  waters  under  the  earth  of  every  clime  are  made  to  con- 
tribute something  to  the  feast.  The  commerce  of  the  world,  in  fact,  is 
largely  occupied  with  providing  for  men's  appetites.  Besides  all  this, 
it  is  man  alone  who  cooks  his  food. 

We  mention  these  facts  because  many  of  the  digestive  troubles 
for  which  physicians  are  consulted  are  not  due  to  the  patients  being 
animals,  but  rather  because  they  are  hxmian  beings  and  hve  as  such. 

STOMATITIS 

The  mucous  membrane  of  the  mouth  is  very  subject  to  inflamma- 
tions, usually  limited  to  the  inner  surfaces  of  the  lips  and  the  cheeks. 
Writers  describe  a  number  of  different  forms,  but  they  all  have,  in 
common,  conditions  of  constitutional  debility,  induced  slowly  by  im- 
proper food  or  defective  hygienic  conditions,  chiefly  in  children  or 
infants.  That  these  affections  of  the  mouth  are  not  of  local  origin  is 
strikingly  illustrated  by  the  prompt  improvement  of  any  one  of  the 
forms  by  change  of  air  or  of  surroundings,  or  in  infants,  change  of  the 
milk  supply. 

Thrush. — One  kind  of  stomatitis,  however,  has  a  specific  origin  in 
the  form  of  an  yeast  fungus,  called  Oidium  albicans,  or  Saccharomyces 
albicans.  Its  ordinary  EngHsh  term  is  "thrush,"  and  the  French, 
"muguet."  But  it  illustrates  the  dependence  of  mouth  inflammations 
upon  constitutional  conditions,  that  the  worst  forms  of  thrush  occur 
in  adults  in  advanced  stages  of  phthisis,  as  well  as  in  diabetes  mellitus; 
while  most  frequently  developing  in  children,  these  facts  show  that 
it  is  by  no  means  confined  to  them,  because  it  should  be  here  noted 

333 


334  CLINICAL  MEDICINE 

that  for  various  reasons  the  period  of  childhood  is  the  most  vulner- 
able period  of  life.  One  evidence  of  this  is  that,  bulk  for  bulk,  the 
blood  of  a  child  is  much  below  that  of  an  adult  in  its  proportion  of  red 
corpuscles.  The  most  certain  remedy  for  deficiency  of  red  corpuscles 
that  we  possess  is  cod-liver  oil,  as  before  mentioned,  and  cod-Kver  oil 
is  the  medicine  of  medicines  for  debihtated  children. 

Treatment. — Besides  attending  to  the  general  health,  stomatitis, 
whether  ulcerative,  aphthous,  or  of  fungous  origin,  should  be  treated 
constantly  with  mouth-washes.  These  may  consist  of  chlorate  of 
potash,  lo  gr.  to  the  ounce,  or  of  sulphite  of  soda,  a  dram  to  the  ounce 
of  peppermint-water,  or  if  the  breath  is  foul,  with  i  gr.  of  permanganate 
of  potash  in  6  oz.  of  cinnamon- water. 

Aphthous  Stomatitis. — One  kind  of  stomatitis  is  called  aphthous. 
This  is  also  known  as  follicular  and  vesicular  stomatitis,  characterized 
by  the  presence  of  small  slightly  raised  spots  surrounded  by  reddened 
areolae,  appearing  first  as  vesicles  which  rupture,  leaving  small  ulcers 
with  bright  red  margins.  They  are  seen  most  frequently  on  the  inner 
surfaces  of  the  lips,  the  edges  of  the  cheeks  and  tongue,  but  not  in  the 
pharynx.  This  form  is  met  with  most  often  in  children  under  three 
years.  The  vesicles  come  out  with  great  rapidity,  and  the  Httle  ulcers 
may  be  fully  formed  within  twenty-four  hours. 

Treatment. — Each  ulcer  should  be  touched  with  nitrate  of  silver, 
and  the  mouth  should  be  thoroughly  cleansed  after  taking  food,  a 
wash  of  chlorate  of  potash,  lo  gr.  to  the  ounce,  or  local  application 
of  the  glycerite  of  borax  being  efficacious. 

Ulcerative  stomatitis  is  often  called  fetid  stomatitis  or  putrid  sore 
mouth.  The  morbid  process  begins  at  the  margin  of  the  gums,  which 
become  swollen  and  red,  bleeding  readily.  Ulcers  form,  covered  with 
a  firmly  adherent  membrane.  They  extend  along  the  gum  line  in 
both  jaws.  Salivation  may  also  occur  and  the  breath  is  foul.  Chlorate 
of  potash  is  very  successful,  both  taken  internally  in  doses  of  lo  gr.  three 
times  a  day  for  a  child,  while  it  may  be  applied  directly  to  the  ulcerated 
surface  as  a  powder.  Sulphite  of  soda,  a  dram  to  the  ounce  of  pepper- 
mint-water, may  also  be  used  as  a  mouth-wash. 

Parasitic  stomatitis  belongs  to  the  order  of  the  yeast  fungi,  and 
consists  of  branching  filaments  from  the  end  of  which  torula  cells 
develop.  The  disease  never  occurs  upon  a  normal  mucosa.  It  begins 
on  the  tongue  in  the  form  of  slightly  raised  white  spots,  which  increase 
in  size  and  gradually  coalesce.  The  membrane  thus  formed  can  be 
readily  scraped  off,  leaving  an  intact  mucosa,  but  the  membrane  may 
extend  over  the  cheeks  and  lips  and  hard  palate,  involving  the  tonsils 


ORAL   SEPSIS  335 

and  the  pharynx,  and  may  even  extend  beyond  this  into  the  esophagus. 
The  mouth  is  usually  dry,  in  contrast  to  the  salivation  accompanying 
aphthae,  and  in  the  treatment  of  a  child's  mouth  it  should  be  kept  scru- 
pulously clean.  Lime-water,  or  a  dram  of  bicarbonate  of  soda  to  a 
tumblerful  of  water,  but  particularly  peppermint-water,  are  useful. 

Gangrenous  stomatitis,  also  called  noma,  is  a  rare  affection,  occur- 
ring almost  exclusively  as  a  sequel  in  measles.  Like  some  gangrenous 
inflammations  elsewhere,  its  onset  may  be  overlooked  from  the  ab- 
sence of  pain.  In  some  cases  the  ulcer  is  very  small,  but  perforates  the 
cheek,  and  it  may  extend,  in  debilitated  children,  to  the  eyelids  above 
and  to  the  jaws  below.  This  affection  is  usually  fatal  within  a  week. 
The  only  local  application  is  the  permanganate  of  potash,  i  gr.  in  6  oz. 
of  cinnamon-water. 

Mercurial  stomatitis,  or  ptyalism,  is  rarely  seen  now  compared  with 
former  times,  when  mercury  was  so  generally  used  for  all  inflammations 
and  in  specific  fevers.  Its  first  symptoms  are  ordinarily  connected 
with  the  teeth,  which  to  the  patient  seem  somehow  to  have  become  too 
long.  A  metallic  taste  is  soon  present  and  with  it  a  very  free  flow  of 
sahva.  In  bad  cases  the  parotid  glands  swtII  and  are  tender  to  press- 
ure. At  present  we  rarely  see  salivation  occur  except  in  those  who 
have  an  idiosyncrasy  against  mercury,  but  such  cases  occur  and  are 
unexpectedly  salivated  by  very  small  doses  of  a  mercurial.  Salivation 
soon  gets  well  spontaneously,  and  should  be  treated  in  all  cases  with 
mild  mouth-washes,  such  as  5  gr.  of  borax  to  the  ounce  of  peppermint- 
water. 

Leukoplakia. — True  leukoplakia  consists  in  the  development  on  the 
dorsum  of  the  tongue  of  a  white  patch,  which  is  wholly  independent  of 
syphilis  or  of  any  of  the  membranous  forms  of  exudation  on  the  tongue 
or  cheeks.  I  have  seen  it  in  cases  where  a  syphilitic  infection  was  out 
of  the  question.  It  is  said  to  be  in  some  patients  a  sign  of  the  approach 
of  cancer  of  the  tongue,  and  hence  should  not  be  treated  with  any 
irritant  applications.  It  is,  however,  a  very  obstinate  affection,  though 
in  its  true  form  it  causes  no  discomfort  whatever,  and  would,  therefore, 
be  better  left  alone. 

ORAL  SEPSIS 
Dr.  W.  H.  Hunter  has  directed  attention  to  the  great  importance 
of  oral  sepsis  as  a  cause  of  serious  disease,  both  of  the  stomach  and 
of  the  intestines.  He  even  claimed  that  infection  of  the  gastric 
mucosa,  by  the  constant  swallowing  of  infected  secretions  from  de- 
cayed  teeth,   was  one  of   the   causes  of  pernicious   anemia.     That 


336  CLINICAL  MEDICINE 

led  me  to  examine  the  mouth  of  every  case  of  pernicious  anemia 
which  came  under  my  observation,  and  I  found  one  instance,  in  a 
policeman,  who  undoubtedly  was  constantly  swallowing  quantities  of 
infected  pus,  with  a  result  that  he  presented  the  identical  picture  of 
pernicious  anemia,  including  nucleated  red  corpuscles  and  myelo- 
cytes in  his  blood,  with  a  high  color-index.  When  his  mouth  was 
attended  to  he  apparently  recovered,  and  remained  well  for  more  than 
a  year,  after  which  I  lost  track  of  him.  But  other  cases  of  pernicious 
anemia  showed  no  evidence  of  oral  sepsis  as  a  cause  of  the  disease. 
Latterly,  Dr.  Hunter  has  returned  to  the  subject,  and  demonstrates 
that  a  great  many  cases  of  infected  dentine  roots  are  masked  or  covered 
-up  by  the  procedures  of  dentists,  so  that  the  most  serious  constitutional 
infection  may  occur  by  the  operation  of  dentists  covering  over  mor- 
bid conditions  of  the  teeth.  I  myself  have  no  doubt  that  his  contention 
is  largely  correct,  for  I  have  repeatedly  relieved  some  obstinate  catar- 
rhal conditions  both  of  the  stomach  and  of  the  intestines  by  thorough 
use  of  an  antiseptic  wash  for  the  teeth,  after  having  other  diseased 
roots  of  the  teeth  extracted.  These  patients  should  use  carbolic  acid 
lotions  night  and  morning,  beginning  with  i  part  of  carbolic  acid  to 
40  of  peppermint-water,  and  gradually  increasing  to  3  or  4  parts  of 
acid.  It  is  not  uncommon  to  find  that  the  tongue  also  becomes  in- 
volved by  a  form  of  glossitis  affecting  its  under  surface,  and  which 
seems  to  have  a  specific  connection  with  this  source  of  infection. 

BAD  BREATH 

Some  writers  speak  of  bad  breath  as  being  due  to  local  conditions 
in  the  mouth  itself,  such  as  carious  teeth,  and  accumulations  in  the 
follicles  of  the  tonsils,  but  these  causes  of  bad  breath  are  insignificant 
compared  with  fecal  accumulation  in  the  lower  bowel.  We  should 
remember  that  the  mucous  membrane  of  the  descending  colon  presents 
an  actively  absorbing  surface,  illustrated  in  our  frequent  recourse  to 
nutritive  enemata.  When  fecal  matter,  therefore,  has  descended  into 
the  lower  bowel  in  a  semifluid  state,  its  watery  constituents  are  rapidly 
absorbed  until,  in  habitual  constipation,  the  contents  become  quite 
hard.  It  is  during  this  absorption  that  the  blood  becomes  charged 
with  volatile-  fecal  odors,  which  are  then  carried  to  the  lungs,  to  be 
exhaled  there,  and  thus  affect  the  breath. 

Treatment. — The  best  treatment  which  I  have  found  for  this  com- 
mon, but  always  disagreeable,  condition  is  to  deal  properly  with  the 
condition  of  the  lower  bowel.  For  this  purpose  a  prescription  of  4 
drams  of  sodium  benzoate,  3I  drams  of  sodium  salicylate,  20  gr. 


AFFECTIONS    OF    THE    ESOPHAGUS  337 

of  thymol,  and  lo  gr.  of  powdered  rhubarb,  divided  into  48  capsules, 
will  soon  correct  the  trouble,  the  dose  being  2  capsules  an  hour  after 
each  meal  and  at  bedtime. 

For  the  condition  in  the  mouth  itself  before  alluded  to,  a  wash  fre- 
quently used  of  ^  pint  of  cinnamon-water  with  20  gr.  of  the  chlorate  of 
potash  will  usually  suffice. 

AFFECTIONS  OF  THE  ESOPHAGUS 

Stricture  of  the  esophagus  may  be  permanent  and  last  for  years, 
and  nevertheless  be  altogether  due  to  nervous  spasm.  I  once  had  a  boy 
ten  years  old  brought  to  me  from  Wappinger  Falls,  N.  Y.,  who  up  to  this 
time  had  always  vomited  his  food  soon  after  taking  it,  but  had  no 
gastric  symptoms  whatever.  Something  seemed  to  collect  in  his 
esophagus,  causing,  when  he  was  asleep,  a  noise  in  the  throat  from 
mucus  collected  in  the  gullet,  until  from  its  quantity  it  awoke  him 
either  to  cough  or  to  vomit.  Upon  taking  solids,  they  were  thrown  up 
the  next  day  unchanged.  When  brought  to  me,  he  was  very  emaci- 
ated from  starvation.  I  then  sent  him  to  a  well-known  surgeon  of  the 
Roosevelt  Hospital,  who  was  sure  that  he  had  an  organic  stricture  of 
the  esophagus,  which  resisted  all  attempts  to  dilate  it  by  bougies.  I 
was  sure,  however,  that  the  stricture  was  simply  spasmodic,  and  there- 
fore, on  my  advice,  the  surgeon  established  a  gastric  fistula  through 
which  he  could  be  fed  by  the  stomach.  The  boy  then  rapidly  gained 
weight,  and  after  allowing  the  esophagus  to  remain  quiescent  for  three 
months,  the  largest  sized  bougie  passed  readily  through  the  site  of 
the  former  stricture,  and  the  patient  was  afterward  fed  exclusively 
T^y  the  mouth. 

Spasmodic  stricture  of  the  esophagus  is  also  not  uncommon  in 
hysteria,  and  may  prove  equally  intractable  until  the  patient  recovers 
froni  appropriate  treatment. 

Every  case  of  apparent  stricture  of  the  esophagus  should  be  care- 
fully examined  to  determine  whether  the  obstruction  in  swallowing 
may  not  be  due  to  pressure  on  the  esophagus  from  growths  or  other 
similar  causes  entirely  outside  the  gullet.  I  was  once  called  in  con- 
sultation by  Dr.  Monae  Lesser,  of  this  city,  to  a  case  of  supposed  stric- 
ture of  the  esophagus  by  cancer,  a  not  unnatural  surmise,  as  the  patient 
was  sixty-seven  years  old  and  had  a  cachectic  appearance.  I  then 
examined  the  spine  of  the  patient,  and  opposite  the  third  and  fourth 
dorsal  vertebrae  found  a  suspicious  area  of  dulness  on  percussion.  I 
then  asked  the  patient  whether  he  could  not  swallow  liquids  if  he  lay 
down,  and  he  said  he  could  if  he  lay  on  his  left  side.  This  answer  ex- 
22 


338  CLINICAL  MEDICINE 

eluded  eaneer,  but  I  soon  found  that  he  had  enlarged  glands  in  his 
neck  and  also  a  number  of  tumors  in  the  abdomen  apparently  con- 
nected with  the  liver.  In  short,  he  was  a  case  of  Hodgkin's  disease, 
some  tumors  of  which  pressed  against  the  esophagus,  but  fell  away  from 
it  when  he  lay  on  his  left  side.  Similarly,  the  physician  should  not 
forget  that  the  esophagus  may  be  pressed  upon  by  an  aneurysm. 

Otherwise  the  esophagus,  when  constricted  at  its  lower  end  near  the 
stomach,  may  become  very  much  dilated  and  its  walls  hypertrophied. 
Food  and  drink  will  accumulate  in  quantity  until  they  are  brought  up 
by  the  efforts  of  the  patient.  Sometimes,  however,  it  consists  mainly 
of  mucus,  not  uncommonly  called  by  nervous  dyspeptics  water-brash. 

Organic  affections  of  the  esophagus  not  due  to  cancer  are  nearly 
always  due  to  the  swallowing  of  caustic  poisons,  such  as  arsenic,  corro- 
sive sublimate,  or  carbolic  acid.  These  not  only  cause  very  painful 
dysphagia  at  the  time,  but  lead  to  chronic  ulcerations  with  cicatricial 
tissue,  narrowing  the  lumen  of  the  tube,  and  which  then  only  can  be 
treated  surgically.  The  esophagus  also  occasionally  has  diverticula, 
which  may  be  elongated  into  narrow  passages  leading,  in  some  recorded 
instances,  to  openings  on  the  skin,  but  such  abnormalities  are  hardly 
more  than  curiosities.  In  the  course  of  the  specific  fevers,  ulcers  may 
form  in  the  esophagus,  during  small-pox,  or  diphtheritic  membranes 
extend  from  the  pharynx  down. 


Disorders  of  the  Stomach 
introduction 

Habits  in  digestion  are  both  physiologic  and  personal.  The  phys- 
iologic habits  are  illustrated  by  the  definite  and  orderly  sequence  of 
secretions,  according  to  the  tract  of  the  alimentary  canal  traversed  by 
the  food.  Thus,  the  saliva  is  first  secreted  in  the  mouth  by  the  stimu- 
lation of  the  presence  of  food  and  by  the  movements  of  mastication. 
The  chief  use  of  saliva  is  to  convert  the  starches  into  sugars,  which  it 
has  time  to  do  when  it  accumulates  for  an  hour  in  the  fundus  of  the 
stomach.  Meantime  the  proteins  of  the  food  are  first  digested  by  the 
gastric  juice  secreted  between  the  fundus  and  the  pylorus,  the  resulting 
acid  chyme  being  discharged  at  intervals  through  the  relaxed  pyloric 
sphincter  into  the  duodenum.  Here  a  remarkable  process  follows,  the 
nature  of  which  has  only  lately  been  demonstrated.  Instead  of  the 
presence  of  the  acid  chyme  in  the  duodenum  stimulating  the  important 


DISOEDERS    OF    THE    STOMACH  339 

pancreatic  secretions  to  flow  by  nervous  reflex,  as  was  once  thought,  a 
substance,  called  secretin  by  Starling,  is  first  formed  in  the  jejunum, 
which  on  being  absorbed  into  the  blood  acts  powerfully  on  the  pan- 
creas. But  this  secretion,  after  it  is  formed,  can  be  isolated  from  the 
jejunum,  and  then  if  injected  anywhere  into  the  blood  it  stimulates  the 
flow  of  the  pancreas  just  the  same  as  if  it  were  absorbed  directly  from 
the  jejunum.  The  small  intestine  is  a  long  digestive  secreting  tract, 
and  Starling's  observations  show  that  for  each  part  its  special  secretion 
is  formed. 

The  ranks  of  no  disciplined  army,  therefore,  could  more  regularly 
take  their  allotted  places  than  do  the  glands  of  the  alimentary  canal 
with  their  well-timed  secretions,  but  these  successive  performances 
take  time.  After  a  full  meal  three  hours  should  be  given  properly 
to  complete  the  work. 

Personal  habits  of  eating  and  of  drinking  may  play  havoc  with 
physiologic  discipline.  Thus,  a  gentleman  called  one  day  whose  coun- 
tenance wore  the  sad  expression  of  a  confirmed  dyspeptic.  This  led 
me  to  begin  with  an  inquiry  into  his  daily  habits  of  eating,  which  should 
always  be  done  with  every  case  of  dyspepsia.  He  said  that  he  always 
took  his  breakfast,  watch  in  hand,  in  order  not  to  miss  the  train,  which 
he  and  his  friends  had  engaged  to  leave  a  suburban  town  at  such  a 
minute  for  an  hour's  ride  to  the  city.  Now  if  there  be  anything  which 
the  stomach  resents  it  is  such  watching.  On  the  train  all  smoked  and 
talked  about  the  day's  money  market  in  Wall  Street.  At  his  next 
meal  he  with  the  same  friends  stood  at  the  counter  of  a  restaurant,  and 
while  eating  were  absorbed  in  discussing  the  stock  quotations.  Toward 
evening  he  had  his  hour's  ride  out  to  take  his  dinner  at  home,  tired 
with  the  day's  business.  That  meal  over,  he  felt  sleepy  and  took  a  nap, 
to  find  afterward  that  he  could  sleep  only  in  snatches  and  with  many 
dreams.  These  digestive  habits  had  been  continued  for  nine  years. 
I  have  had  so  many  similar  experiences  with  business  men  whose  meals 
were  timed  by  express  trains  that  I  can  diagnose  them  at  once  as  "rail- 
road dyspeptics."  It  is  useless  to  treat  such  persons  as  cases  of  chronic 
gastritis,  or  to  prescribe  for  them  reputed  remedies  for  gastritis. 
Change  their  habits,  and  the  long-suffering  stomach  gets  well  spon- 
taneously. 

But  there  is  another  and  specially  human  factor  in  digestion  by 
the  stomach,  and  that  is  mental  interest.  We  are  social  beings,  and  in 
all  ages  men  have  dishked  to  eat  alone.  The  table  is  the  place  for  wit 
and  conversation,  and  in  proportion  as  both  abound  it  is  noteworthy 
how  much  most  dyspeptics  can  eat.     Commonly,  both  in  man  and  in 


340  CLINICAL  MEDICINE 

animals,  fear  and  anger  wholly  arrest  digestion.  Cannon  found  that 
all  movements  of  the  stomach  ceased  in  cats  the  moment  the  animal 
showed  signs  of  anger. 

When  inflammation  or  gastritis  is  actually  present  its  symptoms 
become  objective,  and  the  stomach  should  be  examined  for  them  with 
the  patient  on  his  back  and  the  legs  drawn  up.  The  commonest  of 
•  these  symptoms  is  tenderness  to  pressure  in  the  epigastrium,  with 
muscular  resistance.  Distress  referred  to  the  stomach,  with  nausea 
and  vomiting,  but  with  resistance  to  pressure  absent,  means  something 
else  than  gastritis. 

Normally,  we  should  not  know  that  we  have  either  a  stomach  or 
intestines,  and  our  attention  is  called  to  them  only  when  they  are 
disordered,  hence  the  importance  of  accurately  dating  the  first  sign  of 
such  discomfort.  In  no  class  of  affections  is  the  whole  history  of  the 
patient  so  important.  Thus,  I  disHke  to  hear  a  patient  who  is  past 
middle  Hf e  state  that  he  always  had  perfect  digestion  until  a  few  months 
before,  when  without  anything  to  account  for  it  he  began  to  be  dis- 
tressed after  eating,  because  that  often  means  the  advent  of  gastric 
ulcer.  If,  on  the  other  hand,  he  has  had  the  same  bad  symptoms  for 
years,  cancer  may  be  ruled  out. 

Besides  the  tenderness  and  resistance  to  pressure  at  the  epigastrium, 
the  patient  usually  has  loss  of  appetite,  and  a  sense  of  weight  or  dis- 
tress or  even  pain  after  eating,  with  a  furred  tongue  red  at  the  tip  and 
a  bad  taste  in  the  mouth.  Other  symptoms  often  suggest  the  cause  of 
the  gastritis.  Thus,  old  topers  lose  all  taste  for  a  meat  diet  and  prefer 
milk  and  Vichy.  Morning  nausea  is  common  with  them,  while  they 
hawk  up  quantities  of  tenacious  pharyngeal  mucus  which  they  ascribe 
to  catarrh. 

It  should  be  remembered  that  all  normal  digestive  secretions  have 
two  distinct  functions,  the  first  digestive,  and  the  second  antiseptic  or 
antifermentative,  and  the  symptoms  may  be  mainly  due  to  deficiency 
in  either  of  these  functions.  Thus  it  may  be  difficult  to  decide 
whether  a  case  of  flatulent  dyspepsia  is  due  to  want  of  secretion  or  to 
change  in  its  quaHty.  As  a  rule,  the  latter  is  owing  to  causes  extrinsic 
to  the  stomach  itself,  as  in  portal  congestion  from  heart  disease,  tox- 
emia from  B right's  disease — a  quite  common  cause — or  adhesions  of 
the  pyloric  region  to  contiguous  parts  as  results  of  gastric  ulcer.  All 
cases  of  cirrhosis  of  the  liver  are  also  characterized  by  matting  together 
of  coils  of  the  intestines,  as  well  as  similar  fettering  of  the  stomach  walls. 
The  adhesion  of  the  walls  of  the  alimentary  canal  to  contiguous  parts 
can  never  occur  without  accompanying  symptoms. 


DISORDERS    OF    THE    STOMACH  34 1 

In  the  stomach  as  in  no  other  organ  lined  by  mucous  membrane 
is  the  saying  so  often  illustrated  that  no  mucous  membrane  has  any 
business  to  secrete  mucus.  In  many  disorders  of  the  stomach  we  find 
that  its  mucous  membrane  is  covered  with  thick  tenacious  collections 
of  mucus,  and  scarcely  any  greater  advance  in  treatment  has  occurred 
than  the  practice  of  washing  the  stomach  out,  technically  called  "lav- 
age." Layers  of  such  mucus  may  be  found  in  any  part  of  the  gastric 
cavity,  but  especially  in  the  regions  which  secrete  the  gastric  juice,  with 
the  result  of  greatly  diminishing  the  normal  acidity  of  the  hydrochloric 
acid  necessary  for  digestion.  This  mucus,  besides  being  itself  an  un- 
mistakable sign  of  inflammation,  also  affords  a  nidus  for  the  growth 
and  development  of  micro-organisms,  which  cause  fermentation  and 
the  accumulation  of  irritating  gases.  Instead  of  hydrochloric  acid, 
therefore,  we  have  lactic  acid,  which,  however,  is  rarely  injurious, 
butyric  acid,  which  is  very  irritating,  and  acetic  acid.  Patients  them- 
selves find  out  that  they  are  troubled  with  what  they  call  "a  sour  stom- 
ach." This  form  of  acidity  gives  rise  to  painful  sensations  in  the  epi- 
gastrium and  in  the  esophagus,  a  condition  commonly  called  "heart- 
burn." But  the  stomach,  it  should  be  remembered,  also  presents  an 
active  absorbing  surface,  and  many  poisons  are  absorbed  from  it  di- 
rectly into  the  blood,  producing  such  symptoms  as  headache  and 
depression  of  spirits,  all  of  which  are  typically  present  in  the  affection 
called  migraine  or  sick  headache,  in  which  the  decomposition  of  gastric 
contents  may  cause  actual  vomiting,  as  will  be  further  detailed  in  our 
article  on  Migraine.  The  treatment  of  such  gastric  disorders  resolves 
itself  into  both  prophylactic  and  directly  remedial  measures.  To  the 
prophylactic  class  we  would  rank  first  abstinence  from  all  hurry  in  eat- 
ing or  drinking.  As  we  have  seen,  all  the  steps  in  digestion  are  both 
successive  and  gradual,  the  act  of  mastication  itself  having  been 
demonstrated  by  Pawlow  as  increasing,  through  reflex  action,  the  flow 
of  gastric  juice. 

But  a  further  effect  is  obtained  by  the  thorough  admixture  of  the 
food  during  mastication  with  saliva,  which,  as  we  have  seen,  continues 
its  digestive  effects  in  the  fundus  of  the  stomach  itself.  Besides  delib- 
eration in  eating,  other  factors  enter,  one  of  which  is  that  in  the  case  of 
proteins  there  must  always  be  a  nicely  adjusted  balance  between  the 
intake  of  food  and  the  excretion  of  the  final  products  of  metabolism 
by  the  kidneys.  Thus,  the  excretion  of  urea  is  more  than  double  dur- 
ing eating  than  during  fasting.  If  the  kidneys  are  chronically  dis- 
eased, this  additional  work  caused  by  eating  may  so  raise  the  blood- 
pressure  as  to  bring  on  apoplexy.     On  that  account  more  cases  of 


342  CLINICAL   MEDICINE 

apoplexy  occur  just  after  a  Christmas  or  Thanksgiving  dinner  than 
at  other  times. 

This  is  a  proper  place  to  allude  to  the  use  of  alcoholic  drinks.  The 
statement  cannot  be  too  clearly  emphasized  that  if  people  would  take 
alcoholic  drinks  only  while  they  were  eating  there  would  be  no  drunk- 
ards. There  is  a  natural  antagonism  between  alcohol  and  food.  Dur- 
ing the  act  of  eating  the  stomach  will  allow  only  a  comparatively  Hmited 
amount  of  alcohol  to  be  taken.  If  this  Hmit  be  exceeded,  digestion 
stops,  to  be  followed  by  vomiting  of  the  food,  unless  the  stomach  is 
spared  further  alcoholic  addition.  But  this  fact  is  illustrated  still 
more  strikingly  in  cases  of  chronic  alcoholism.  One  of  the  best  signs 
that  a  man  is  taking  too  much  alcohol  for  his  good  is  that  he  no  longer 
chooses  to  eat  beefsteak  or  other  meats,  but  prefers  to  take  swallows  of 
milk  and  Vichy.  So  in  proportion  as  he  indulges  in  alcohoUc  drinks 
he  loses  all  desire  for  hearty  food,  until  his  abstinence  becomes  ex- 
treme. I  have  not  known  a  case  of  dehrium  tremens,  either  in  hos- 
pital or  private  practice,  who  had  taken  anything  to  eat  for  a  week  or 
more,  and  the  first  indication  in  the  treatment  of  dehrium  tremens  is 
not  only  to  stop  alcohol,  but  also  to  feed  the  patient,  for  it  is  only  the 
taking  of  food  which  counteracts  the  craving  for  more  hquor.  But 
though  many  persons  may  not  take  enough  liquor  at  one  time  to 
become  intoxicated,  yet,  by  very  frequent  tipphng,  they  will  in  time 
present  symptoms  which  are  truly  characteristic  of  their  condition. 
The  hands  are  large  and  soft,  the  throat  is  congested  and  covered  with 
slimy  tenacious  mucus,  which  induces  morning  hawking,  with  some- 
times vomiting.  These  people  never  take  a  hearty  meal.  Their 
sleep  is  also  imperfect,  and  the  action  of  the  bowels  is  scanty  and  irreg- 
ular. They  become  generally  sluggish  in  their  movements  and  fitful 
in  all  mental  exertion.  In  other  words,  the  man  has  lost  his  grip  upon 
hfe.  I  have  often  told  such  patients  that  they  were  taking  too  much 
alcohol  for  their  good,  and  have  had  them  emphatically  deny  that  they 
were  topers  because  they  were  never  drunk.  I  have,  therefore,  tested 
them  in  this  way,  asking  them  to  take  an  empty  pint  bottle  and  fill 
it  with  whisky  and  then  find  how  long  this  whisky  would  last.  They 
will  commonly  insist  that  it  will  last  them  several  days,  only  to  be 
afterward  astonished  to  find  it  is  all  used  up  before  one  day  is  finished. 

As  is  well  known,  one  of  the  most  common  results  of  alcoholism  is 
disease  of  the  hver,  either  in  the  form  of  hypertrophic  or  atrophic 
cirrhosis.  As  all  the  blood  of  the  stomach  has  subsequently  to  pass 
through  the  liver,  it  can  readily  be  seen  that  chronic  congestion  of  the 
mucous  coats  of  the  stomach  must  follow,  with  a  tendency  to  actual 


DISORDERS    OF    THE    STOMACH  343 

ulceration.  This  is  especially  the  case  when  the  alcohol  has  been 
taken  on  an  empty  stomach,  and  the  downward  course  of  such  victims 
often  begins  with  a  morning  cocktail.  Continuous  alcoholic  craving 
is  particularly  liable  to  occur  in  those  who  take  stimulants  when  the 
stomach  is  empty. 

One  rule  to  go  by  for  prc*scribing  or  prohibiting  the  taking  of  alcohol 
depends  upon  examination  of  the  urine.  If  this  be  neutral  or  alkaline 
and  loaded  with  phosphates,  the  patients  are  nervous  and  sleepless 
with  a  tendency  to  loss  of  flesh.  Their  nervous  condition,  therefore, 
calls  for  a  sedative.  In  our  chapter  upon  Remedies  we  have  spoken  of 
an  important  class  of  nervines  which  are  both  stimulant  and  sedative 
at  the  same  time,  meaning  that  they  are  stimulant  to  certain  ner\^e 
functions  and  simultaneously  depressing  to  others. 

This  is  pre-eminently  the  case  with  alcohol,  for  while  it  is  a  stimu- 
lant to  certain  mental  functions  and  also  to  the  action  of  the  heart,  it  is 
at  the  same  time  powerfully  sedative  to  all  reflex  impression.  Thus, 
if  a  person  in  health  should  take  a  full  dose  of  brandy,  he  wiU  find 
that  on  testing  with  the  proper  instrument  his  tactile  sensations — at 
the  tip  of  a  ring-finger  and  the  tip  of  the  tongue — their  sensitiveness  is 
markedly  decreased.  With  a  further  increase  of  alcohol  he  no  longer 
knows  where  his  feet  are,  and,  therefore,  staggers  in  walking.  This  is 
not  due  to  motor  paralysis,  as  a  drunkard  soon  shows  on  becoming 
excited,  but  is  due  to  that  depression  of  the  sensory  muscular  nerves 
which  is  indispensable  for  muscular  co-ordination.  But  in  many  cases 
of  nervous  debility  reflex  excitability  of  the  sensory  nerves  is  so  in- 
creased that  sleep  or  ordinary  quiet  is  impossible,  and  in  time  the 
patients  are  worn  out  by  the  imdue  irritability  of  their  surface  nerves. 
With  them  the  sedative  action  of  alcohol  is  invaluable  in  promoting 
sleep  and  a  return  to  health. 

As  before  stated,  they  should  never  take  alcohol  except  while  eat- 
ing, a  fact  to  be  borne  in  mind  by  the  physician  when  he  assumes  the 
responsibility  of  recommending  the  patients  to  take  this  agent.  On 
the  other  hand,  if  the  urine  is  diminished  in  quantity,  with  high  color 
and  increased  specific  gravity,  no  matter  from  what  causes,  a  physician 
should  not  think  of  prescribing  alcoholic  stimulants. 

A  physician  is  often  asked  about  tobacco,  and  many  solemn  warn- 
ings against  tobacco  are  uttered  by  those  who  do  not  use  it.  No  agent, 
not  even  alcohol,  is  so  universally  used  in  all  times  and  countries  as 
tobacco  since  its  introduction  from  America  in  the  early  part  of  the 
17th  century,  and  the  failure  to  show  that  tobacco  has  in  any  way 
injured  the  human  race  or  increased  its  proclivity  to  disease  proves 


344  CLINICAL  MEDICINE 

how  harmless  tobacco  is.  On  the  other  hand,  Hke  any  other  agent, 
excess  in  its  use  may  do  harm  to  certain  functions,  which  are  easily  de- 
fined. Thus,  excess  in  tobacco  deranges  the  action  of  the  heart,  and  it 
should  be  prohibited  in  all  cases  of  marked  cardiac  debility.  It,  how- 
ever, should,  if  possible,  be  used  after  meals,  for  the  gastric  juice  has  a 
great  effect  in  modifying  it,  and  likewise  it  is  best  not  to  smoke  in  the 
open  air.  Thus,  a  man  should  not  smoke  a  cigar  while  driving  a 
horse,  for  the  rapid  current  of  air  causes  a  generation  in  the  hghted 
cigar  of  a  poisonous  fusel  oil  which  makes  the  hand  very  unsteady. 

ACUTE  GASTRITIS 

This  condition  may  have  many  exciting  causes.  One  of  them  is  the 
swallowing  of  corrosive  poisons,  often  with  suicidal  intent.  The  symp- 
toms, then,  are  those  of  burning  pain  referred  to  the  epigastrium  and 
violent  vomiting.  No  time  should  be  lost  in  administrating  the 
,  proper  antidotes.  The  patient  complains  of  burning  thirst,  and  should 
be  allowed  to  drink  water  very  freely,  which,  in  fact,  may  make  the 
vomiting  easier.  Some  cases  of  acute  gastritis  from  swallowing  corro- 
sive poison  have  been  reported  whose  after-effects  have  been  an  extra- 
ordinary wasting  of  the  stomach,  with  contractions,  so  that  it  can  con- 
tain but  a  fraction  of  its  ordinary  contents. 

The  commonest  cause  of  acute  gastritis  in  adults  is  due  to  the  taking 
of  large  quantities  of  alcohol  upon  an  empty  stomach;  fortunately, 
nature  very  commonly  reheves  them  by  active  vomiting.  It  is  other- 
wise when  acute  gastritis  occurs  at  the  onset  of  the  specific  fevers. 
The  stomach  trouble  then  is  one  of  the  compHcations  of  the  complaint, 
which  usually  will  soon  subside  with  the  progress  of  the  disease. 

Among  the  other  and  more  common  causes  of  acute  gastritis  is 
the  ingestion  of  improper  articles  of  food,  especially  unripe  fruit.  In 
such  cases  the  mucous  membrane  is  everywhere  reddened.  Vomiting, 
in  fact,  is  a  great  preservative  of  the  stomach  from  serious  inflamma- 
tion by  the  retention  of  irritant  particles. 

Treatment. — The  first  indication  in  the  treatment  for  such  cases 
is  to  give  wineglassful  doses  of  equal  parts  of  milk  and  Hme-water,  at 
intervals  of  fifteen  minutes,  until  the  symptoms  subside. 

CHRONIC  GASTRITIS 

The  occurrence  of  chronic  gastritis  from  the  various  causes  which 
we  have  enumerated  in  time  produces  organic  changes  in  the  mucous 
and  submucous  tissues  of  the  stomach.     This  is  especially  illustrated 


CHRONIC   GASTRITIS  345 

in  the  region  of  the  pylorus.  The  first  changes  there  are  shown  by  an 
increase  in  the  folds  of  the  pyloric  mucous  membrane;  afterward  in  a 
hypertrophy  of  the  submucous  layers,  which  may  or  may  not  be  ac- 
companied by  ulceration,  but  which  often  ends  in  such  thickening 
or  contraction  as  seriously  to  interfere  both  with  the  movements  of  the 
stomach  and  with  the  proper  emptying  of  food  through  the  pyloric 
canal  into  the  duodenum.  This  pyloric  obstruction  in  time  leads  to 
dilatation  of  the  stomach  itself,  with  other  disorders  to  be  described 
later. 

Treatment. — In  the  treatment  of  chronic  gastritis  the  first  object, 
as  we  might  expect,  is  a  painstaking  inquiry  into  the  habits  of  eating  of 
the  patient.  Many  cases  of  inveterate  dyspepsia  leading,  it  may  be,  to 
obstinate  vomiting  or  pain  after  eating  may  be  reUeved  by  change  of 
diet  alone.  For  this  purpose  milk  takes  the  most  important  place. 
Milk  contains  all  the  elements  out  of  which  the  body  may  be  built,  as 
is  shown  by  the  growth  of  infants  and  young  children,  for  every  tissue 
of  the  body  is  built  up  out  of  materials  furnished  by  milk.  On  that 
account  we  cannot  imitate  artificially  such  a  universal  food.  On  the 
other  hand,  in  the  case  of  cows'  milk,  adults  particularly  find  this  article 
rather  indigestible.  The  reason  for  this  is  not  far  to  seek,  for  the  first 
step  in  digestion  of  milk  is  the  precipitation  of  its  casein,  a  process 
which  uses  up  a  large  part  of  the  pepsin  of  the  stomach,  so  that  not 
enough  is  left  for  the  further  digestion  of  the  precipitated  casein  or  curd 
into  a  liquid  which  can  be  absorbed.  All  races,  therefore,  who  have  to 
live  entirely  upon  milk,  such  as  the  Bedouins,  the  Tartars,  and  the 
Gauchos,  of  South  America,  ferment  the  milk  first;  in  fact,  all  people  in 
Western  Asia  do  the  same,  using  for  this  purpose  the  yeast  plant;  while 
the  Tartars  use  a  lichen  called  kefir  for  the  same  purpose.  This  proc- 
ess of  fermenting  usually  takes  from  ten  to  twelve  hours.  The  fer- 
mented milk  should  then  be  smooth  and  not  hke  ordinary  sour  milk, 
having  a  slightly  acid  flavor.  The  best  way  to  use  it  is  not  to  drink  it 
in  any  quantity  at  a  time,  but  to  take  it  as  one  would  take  soup,  because 
it  is  best  borne  when  the  stomach  has  had  time,  as  in  the  taking  of  soup, 
to  adjust  itself  to  the  intake  of  this  food.  In  many  cases  it  is  better  to 
break  bread  into  the  milk,  and  there  is  no  objection  to  sweetening  it 
with  sugar  by  those  who  so  prefer  it.  I  have  cured  cases  of  obstinate 
dyspepsia,  and  many  of  them  accompanied  by  vomiting,  by  the  use  of 
these  fermented  milks,  which  I  was  the  first  to  introduce  into  this 
country,  and  which  are  now  sold  extensively  under  the  name  of  koumiss 
or  zoolak,  which  is  fermented  milk  bottled,  there  being  numerous 
preparations  of  the  same  kind  on  the  market. 


346  CLINICAL  MEDICINE 

Medicinal  Treatment. — Besides  regulating  the  diet,  as  we  have 
mentioned,  some  medicines  have  a  decidedly  curative  effect.  Of 
these  the  first  is  the  bichromate  of  potash,  recommended  by  Professor 
Fraser,  of  Edinburgh,  which  may  be  prescribed  in  pill  form: 

I^.      Kal.  bichrom gr.  iss; 

Bismuth,  subcarb 3  iss; 

Extract,  gentian q.  s.  — M. 

Ft.  pil.  XXX. 
Sig. — One  pill  one-half  hour  before  each  meal. 

and  the  following: 

Resorcin 3ij; 

Tinct.  nucis  vomicae 3  iij ; 

Syrup,  zingiberis §  iss; 

Aquas  menthae ad.  §  vi. — M. 

Sig. — Two  teaspoonfuls  in  water,  one-half  hour  after  meals  and  at  bedtime. 

A  very  serviceable  remedy  for  chronic  gastritis  with  ulcer  is  pow- 
.  dered  condurango,  which  may  be  given  in  the  following  prescription : 

I^.      Pulv.  conduran.     )  ^.        ,, 

^.         ,        ,       ,     > aa  oiv. — M. 

Bismuth,  subcarb.  i 

Ft.  pulv.  xvi. 

Sig. — One  powder  an  hour  after  each  meal. 

It  is  in  chronic  gastritis  that  gastric  lavage  is  so  beneficial.  Usually 
I  gallon  of  water  introduced  through  a  stomach-tube  answers.  The 
mucous  membrane  of  the  stomach  in  all  cases  of  chronic  gastritis  is 
covered  with  a  thick  coating  of  mucus,  which  greatly  interferes  with 
the  normal  gastric  secretions  and  should  be  washed  until  no  mucus 
appears  in  the  return  flow.  If  there  is  much  mucus,  it  may  be  advisable 
to  wash  with  an  alkaUne  solution,  of  which  as  good  as  any  is  2  drams 
of  sodium  bicarbonate  to  the  quart  of  water.  The  best  time  for  lavage 
is  in  the  morning  before  breakfast. 

PHLEGMONOUS  GASTRITIS 

This  is  mentioned  in  medical  literature,  but  is  of  very  rare  occur- 
rence. Theoretically,  it  might  follow  the  impaction  in  a  gastric  artery 
by  an  embolus.  It  may  be  due  to  direct  infection  of  a  lesion  in  the 
stomach  by  pyogenic  micro-organisms  like  the  Streptococcus  pyogenes 
or  the  Staphylococcus  pyogenes  aureus. 

The  symptoms  are  those  of  an  acute  pain  referred  to  the  epigastrium, 
with  other  symptoms  of  localized  inflammation  and  with  the  rapid 
development  of  leukocytosis.  Its  accurate  diagnosis  is  at  a,ll  times 
difhcult,  and  is  best  treated  surgically  by  an  exploratory  incision. 


GASTRODUODENAL    ULCERS  347 

GASTRODUODENAL  ULCERS 

Authors  differ  in  their  statistics  of  the  occurrence  of  typical  gastric 
ulcer  as  shown  postmortem  either  by  its  presence  or  by  the  scars 
which  it  has  produced.  Some  put  it  so  low  as  5  per  cent.  There  can 
be  no  doubt  that  the  figures  vary  in  different  locaUties,  but  it  is  com- 
mon enough  everywhere.  Notwithstanding  both  its  frequency  and 
the  definiteness  of  the  anatomic  characters  of  these  ulcers,  there  is 
no  more  agreement  about  their  causation  than  there  is  about  the  eti- 
ology of  mahgnant  diseases. 

The  reason  for  this  is  due  to  the  fact  that  such  an  ulcer  cannot  be 
produced  artificially,  a  fact  which  should  not  be  forgotten  in  discuss- 
ing its  pathology.  If  only  we  could  experimentally  cause  one  of  these 
ulcers  to  begin  and  then  go  through  all  its  stages  by  measures  of  our 
own,  the  problem  would  be  well  nigh  solved.  But  experimental 
lesions  of  the  gastric  walls,  such  as  Lauder  B  run  ton  caused  by  small 
ligatures,  or,  in  fact,  any  other  injuries  to  them,  whether  designed  or 
accidental,  heal  as  quickly  as  similar  lesions  do  on  the  surface  of  the 
body.  Whatever  the  nature  of  these  lesions,  they  never  produce  a 
typical  gastric  ulcer.  That  the  caustic  gastric  juice,  so  commonly  as- 
signed as  the  cause  of  the  persistence  of  ulceration,  when  once  a  lesion 
happens  in  the  gastric  mucosa,  has  really  Httle  to  do  with  it,  is  shown  by 
artificial  ulcerations  heaUng  just  as  surely  whether  there  be  gastric 
juice  present  or  not. 

Such  being  the  case,  many  theories  on  this  subject  must  be  expected. 
Thus,  in  Dr.  C.  F.  Martin's  able  article  on  gastric  ulcer  in  Osier's 
"System  of  Medicine,"  I  have  counted  thirty-six  different  theories 
propounded  by  sixty- two  authors,  with  the  agreements  on  any  one 
statement  numbering  only  nine.  Other  writers  on  diseases  of  the  stom- 
ach, such  as  Boas,  Hemmeter,  Ewald,  and  Einhorn,  increase  the  list 
of  both  discordant  theories  and  of  disagreeing  writers. 

This  subject,  in  fact,  is  closely  bound  up  with  the  question  why  the 
healthy  stomach  does  not  digest  itself,  which  it  quickly  does  when 
sudden  death  occurs  shortly  after  a  meal  is  taken.  The  old  view  of 
Hunter  that  living  tissue  cannot  be  thus  digested  because  of  its  being 
living,  was  seemingly  disposed  of  by  Claude  Bernard,  who  caused  a 
living  frog's  leg  to  be  wholly  eaten  away  by  introducing  it  into  the 
gastric  fistula  of  a  dog.  He  also  produced  the  same  result  by  introduc- 
ing the  Hving  leg  in  a  vial  filled  with  artificial  gastric  juice,  and  he, 
therefore,  concluded  that  the  effect  was  solely  due  to  the  chemical 
action  of  the  hydrochloric  acid  in  the  secretion.  But  this  leaves  the 
question  just  where  it  was,  for  if  a  live  frog's  leg  can  be  eaten  away, 


348  CLINICAL  MEDICINE 

either  in  a  fistula  or  in  a  vial,  why  does  not  this  active  juice  eat  a  hole 
through  the  stomach  every  time  it  is  secreted  in  us? 

But  the  same  question  arises  in  the  case  of  the  pancreatic  secretion, 
which  certainly  is  active  enough  to  digest  anything  which  the  gastric 
juice  can  digest.  Some  writers  infer  that  as  the  usual  location  of  du- 
odenal ulcers  is  above  where  the  pancreatic  secretion  flows  into  the 
intestine,  it  is,  therefore,  still  the  gastric  juice  discharged  through  the 
pylorus  which  produces  duodenal  ulcers.  But,  as  we  have  shown 
that  the  gastric  juice  cannot  itself  produce  gastric  ulcers,  it  is  less  likely 
it  can  cause  ulcers  in  the  duodenum.  Moreover,  cases  have  been  re- 
ported of  gastric  ulcers  in  young  infants  and  even  in  antenatal  cases, 
where,  of  course,  no  flow  had  yet  occurred,  either  of  gastric  or  pan- 
creatic secretion.  In  addition,  we  may  refer  to  those  duodenal 
ulcers  which  occur  after  extensive  burns  of  the  skin,  and  which  must 
be  due  to  very  different  causes  from  those  of  t3rpical  gastric  ulcers. 

We  may  now  quote  further  illustrations  of  the  perplexity  which 
this  problem  causes  among  authors.  Thus,  Striimpell  says:  "It 
is  not  known  what  the  special  causes  are  which  occasion  the  primary 
damage  to  the  (stomach)  tissue,  nor  why  the  loss  of  substance  is  not  at 
once  healed,  but  extends  in  width  and  depth.  While  there  is  no  lack 
of  theories  to  solve  these  questions,  explanation  of  the  fact  that  the 
normal  gastric  mucous  membrane  is  not  attacked  by  gastric  juice 
lies  in  the  intrinsic  vital  resisting  power  of  the  normal  living  cells. 
In  a  word,  our  present  knowledge  of  the  development  and  extension  of 
gastric  ulcer  is  very  limited."  Hemmeter  says:  "The  question  of  the 
exemption  of  the  stomach  from  self-digestion  remains  unanswered. 
When  Hunter  over  one  hundred  years  ago  (1786)  referred  the  immun- 
ity to  a  specific  property  of  the  living  cells,  'the  vital  principle,'  he 
gave  as  good  an  explanation  as  any  given  up  to  date." 

Howell  says:  "When  we  come  to  consider  all  the  evidence,  noth- 
ing seems  clearer  than  that  the  protection  of  the  living  tissue  is  in  every 
case  due  to  the  properties  of  its  living  structure.  So  long  as  the 
tissue  is  alive,  it  is  protected  from  the  action  of  the  digesting  secre- 
tion, but  the  ultimately  physical  or  chemical  reason  for  this  is  yet  to  be 
discovered." 

At  this  point  it  seems  to  me  that  a  ray  of  light  has  been  thrown 
on  this  obscure  subject  by  a  remark  of  Prof.  Halliburton  when  he  says: 
"Recent  studies  on  the  important  subject  of  immunity  have  furnished 
us  with  a  key  to  the  problem  {i.  e.,  why  the  stomach  and  the  duodenum 
as  well  are  protected  from  self-digestion) .  Just  as  poisons  from  with- 
out stimulate  the  cells  to  produce  antitoxins,  so  harmful  substances 


GASTRODUODENAL   ULCERS  349 

produced  within  the  body  are  provided  with  antisubstances  capable 
of  neutraHzing  their  effects,  and  for  this  reason  the  blood  does  not  clot 
within  the  blood-vessels.  Weissland  has  shown  that  the  gastric  epi- 
thelium forms  an  antipepsin,  and  the  intestinal  epithelium  an  anti- 
trypsin, etc. 

This  has  lately  been  put  to  practical  use  in  treatment  with  markedly 
beneficial  results.  Thus,  Dr.  E.  C.  Hort,  of  London,  has  been  suc- 
cessfully treating  these  ulcers  by  inducing  a  condition  of  immunity 
of  the  gastric  mucosa  to  the  action  of  those  gastrolytic  toxins,  which 
first  cause  and  then  render  permanent  the  ulcers.  Dr.  Hort  was  first 
led  to  these  views  by  the  success  of  Dr.  Emil  Weiss,  of  Paris,  in  the 
treatment  of  hemophilia  and  of  severe  hemorrhages  occurring  in  pur- 
pura by  the  administration  of  fresh  animal  serum.  This  is  now 
becoming  a  well-recognized  procedure  in  various  forms  of  hemorrhage. 
Thus,  the  author,  lately  treated  a  lady  aged  forty-eight,  who,  beginning 
with  large  extravasations  -of  blood  under  the  skin  in  various  parts  of 
the  body,  had  her  life  threatened  by  profuse  hematuria.  Every 
means  for  checking  the  bleeding,  including  the  free  administration  of 
calcium  salts,  failed  until  15  c.c.  of  rabbits'  serum  were  given  h>'po- 
dermically  once  a  day,  whereupon  the  general  hemorrhage  stopped 
and  the  hematuria  ceased. 

Dr.  Hort  says  that  he  has  uniform  success  iujarresting  severe  hema- 
temesis  with  normal  horse  serum  given  by  the  mouth,  and  equally  so  with 
cases  of  chronic  gastric  ulcer  without  hemorrhage  in  the  consequent 
subsidence  of  the  symptoms,  like  pain  and  vomiting.  Among  his 
reports  are  those  of  a  case  of  severe  recurring  ulcer  duruig  seven  years, 
in  which  for  two  days  10  c.c.  of  normal  horse  serum  were  given  by 
the  mouth  in  milk.  No  other  treatment  was  followed  except  increasing 
the  serum  doses  daily,  so  that  on  the  twenty-seventh  day  30-c.c.  doses 
were  administered,  after  which  the  patient  wholly  recovered. 

In  short,  Dr.  Hort's  treatment  of  gastroduodenal  ulcer  is  to  admin- 
ister not  less  than  30  c.c.  of  horse  serum  a  day,  beginning  with  from 
10  to  15  c.c.  at  a  dose  by  mouth  in  milk,  or  in  |  oz.  of  water,  and  never 
on  an  empty  stomach.  If  the  pain  is  severe  or  there  is  hemorrhage, 
from  60  to  80  c.c.  may  be  given  in  twenty-four  hours,  the  treatment  to 
continue  for  six  weeks  or  longer.  It  is  best  to  continue  it  for  some 
weeks  after  apparent  cure. 

The  further  progress  of  a  gastroduodenal  ulcer  varies  widely  in 
different  cases.  In  many  the  contiguous  mucous  membrane  prolifer- 
ates a  granulation  tissue,  which  fills  up  the  ulcer  and  soon  heals.  In 
other  cases  distinct  inflammatory  processes  occur,  around  the  walls  of 


350  CLINICAL  MEDICINE 

the  ulcer,  so  that  when  it  heals  it  leaves  a  permanent  scar.  In  other 
cases  very  chronic  inflammatory  conditions  occur,  so  that  the  resulting 
ulcer  may  not  heal,  but  persists  for  an  indefinite  period.  These  ulcera- 
tive processes  may  extend  widely,  with  serious  results,  according  to  their 
site  and  depth.  Thus,  not  uncommonly  the  canal  of  the  pylorus  may 
become  stenosed  by  the  contraction  of  the  cicatrices  caused  by  the 
ulcerative  process,  with  subsequent  dilatation  of  the  stomach.  In  a 
few  cases  these  inflammatory  processes  may  encircle  the  stomach, 
and  produce  by  their  contraction  what  is  termed  an  "hour-glass 
stomach."  More  frequently,  however,  the  ulcerative  process  extends 
to  contiguous  parts  and  produces  adhesions  between  the  stomach  and 
surrounding  tissues.  This  is  particularly  the  case  when  the  original 
site  of  the  ulcer  was  close  to  the  pylorus. 

The  extensive  experience  of  surgeons  shows  that  ulcers  of  the 
duodenum  are  fully  as  common  as  those  of  the  stomach,  and  with  the 
difference  that  duodenal  ulcers  occur  more  commonly  in  men  than 
in  women.  Duodenal  ulcers  also  are  more  prone  to  end  in  prolifera- 
tion than  gastric  ulcers.  Surgeon  D'Arcy  Power,  F.  R.  C.  S.,  reports 
3  cases  admitted  to  St.  Bartholomew's  Hospital  in  the  month  of 
June  and  a  fourth  case  in  the  following  month.  In  3  of  his  cases 
perforation  occurred  without  any  warning,  the  patients  being  at  work 
at  the  time  of  its  occurrence.  Their  lives  were  saved  by  a  prompt 
removal  to  the  hospital,  and  then  by  immediate  operation.  This 
shows  the  necessity  of  careful  watching  of  the  symptoms  in  this  form  of 
ulceration.  If  the  case  has  been  at  all  chronic,  the  symptoms  already 
described  are  sure  to  be  present. 

These  ulcers,  both  in  the  stomach  and  in  the  duodenum,  often  cause 
fatal  hemorrhage  by  penetrating  the  coats  of  an  artery.  On  the 
other  hand,  the  ulcer  is  often  quite  chronic  and  then  of  much  larger 
size,  the  margin  is  not  sharp,  with  the  edges  indurated  and  the  border 
sinuous.  In  other  words,  extensive  inflammatory  changes  may  occur 
both  in  the  ulcer  and  in  its  immediate  surroundings.  In  such  cases  the 
floor  may  involve  the  deeper  layers  of  the  mucosa  or  the  muscular 
layers,  or  quite  frequently  invade  neighboring  organs,  thus  attaching 
them  to  the  stomach.  According  to  the  extension  of  this  process,  a 
superficial  ulcer  may  fill  up  and  leave  nothing  but  a  smooth  scar,  but 
in  the  larger  ulcers  just  described  the  cicatricial  contraction  ma}^ 
cause  serious  changes,  the  most  important  of  which  is  narrowing  of  the 
pyloric  orifice  and  consequent  dilatation  of  the  stomach.  These  large 
ulcers  may  persist  for  years  without  any  attempt  at  healing. 

Modern  surgical  experience  has  greatly  increased  the  frequency 


CHRONIC    GASTRODUODENAL    ULCERS  35 1 

of  the  incidence  of  gastroduodenal  ulcerations,  proving,  among  other 
things,  that  the  duodenal  ulcers  occur  much  oftener  in  the  male  than 
in  the  female.  As  to  sex,  the  largest  number  among  females  occurs 
between  fifteen  and  twenty-five,  and  among  males  between  forty  and 
fifty.  Of  the  gastric  ulcers,  90  per  cent,  are  found  at  the  pyloric 
end,  while  nearly  all  duodenal  ulcers  are  close  to  the  opening  of  the 
pylorus.  They  may,  however,  occur  anywhere  on  the  walls  of  the 
stomach,  more  frequently  on  the  lesser  curvature  and  posterior  wall. 

Chronic  Gastroduodenal  Ulcers 

The  further  course  of  these  ulcers  greatly  varies  in  different  cases. 
In  many  patients  the  ulcerative  process  becomes  chronic  by  having 
engrafted  upon  it  distinctly  inflammatory  processes;  the  margins  of 
the  ulcers  become  greatly  altered  from  infiltration  of  the  products  of 
-the  chronic  inflammatory  processes,  and  may  extend  so  that  the  ulcer 
presents  very  little  resemblance  to  the  simple  round  and  clean-cut  lesion 
at  the  beginning.  In  some  cases  heahng  takes  place,  with  the  presence 
of  cicatricial  tissue,  leaving  a  permanent  scar  over  the  site  of  the  ulcer. 
In  other  cases  the  ulcerative  process  extends  more  widely  and  deeper, 
until  not  only  all  the  coats  of  the  stomach  itself  are  involved,  but  ex- 
tensive adhesions  may  occur  to  perigastric  tissues.  This  is  notably 
the  case  in  ulcers  situated  near  the  pylorus,  whose  canal  may  be  so 
diminished  by  cicatrization  as  to  produce  serious  obstruction  to  the 
discharge  of  the  gastric  contents  into  the  duodenum,  with  consequent 
dilatation  of  the  stomach  itself. 

The  symptoms  of  duodenal  ulcers  ordinarily  differ  from  gastric 
ulcers  in  the  following  particulars: 

Pain  after  eating  does  not  occur  so  often  as  in  gastric  ulcers,  but 
usually  from  two  to  three  hours  after  a  meal.  So  often  is  this  the  case 
that  it  has  received  the  name  of  "hunger  pain,"  which  is  further  em- 
phasized by  the  fact  that  it  is  often  relieved  by  taking  small  quantities 
of  food.  The  site  of  the  pain  and  tenderness  on  pressure  is  oftener 
to  the  right  of  the  median  line,  and  rarely  radiates  to  the  back,  as  in  the 
case  of  gastric  ulcer.  Nausea  and  vomiting  also  are  rare  in  duodenal 
ulcers. 

Hemorrhage,  on  the  other  hand,  in  duodenal  ulcers  may  commonly 
take  the  form  of  melena,  though  it  may  be  concealed  and  detected 
only  by  examination  for  occult  blood  in  the  feces.  As  in  the  case  of 
gastric  ulcers,  duodenal  ulcers  may  be  very  chronic  and  lead  to  cica- 
trization, with  consequent  symptoms  difficult  to  distinguish  from  those 
of  pyloric  obstruction.     When  these  ulcers  are  very  chronic  and  are 


352  CLINICAL  MEDICINE 

not  relieved  by  medical  means,  a  surgical  excision  is  indicated,  for  in 
no  conditions  has  modern  surgery  proved  more  successful  than  in  deal- 
ing with  such  ulcerations  in  the  alimentary  canal. 

Treatment. — Dr.  R.  C.  Kemp,  in  his  book  on  "Diseases  of  the  Stom- 
ach, Intestines,  and  Pancreas,"  2d  edition,  page  346,  highly  recom- 
mends the  employment  of  gelatin  in  conditions  of  hyperchlorhydria 
and  in  ulcerative  conditions  of  the  stomach.  He  states:  "I  have  found 
gelatin  an  excellent  remedy,  employing  i,  2,  or  even  3  oz.  of  a  5  to  10 
per  cent,  gelatin  solution,  flavored  with  a  pinch  of  sugar  or  a  little 
vanilla,  and  given  midway  between  meals. 

Hemorrhage  from  gastric  ulcer  varies  so  much  in  degree  that  its 
treatment  must  be  managed  accordingly.  In  most  cases  perseverance 
with  a  resorcin  mixture,  given  heretofore,  and  the  bichromate  pill, 
may  be  quite  sufificient,  along  with  absolute  rest  in  bed  and  temporary 
abstinence  from  all  food.  In  other  cases  the  hemorrhage  is  so  profuse 
that  other  measures  must  be  adopted,  the  first  place  being  given  to 
Lenhartz's  treatment. 

Lenhartz  believes  that  many  cases  of  gastric  ulcer  do  not  definitely 
improve,  or  but  very  slowly,  under  the  method  of  entrenched  milk 
feeding;  that  the  high  acidity  is  not  measurably  lessened;  and  that  if 
patients  are  in  a  poor  physical  condition,  consequent  upon  one  or  more 
hemorrhages,  often,  indeed,  in  collapse,  the  "starvation  treatment" — 
the  ice  and  nutrient  enemata  and  insufficient  milk  feeding  following — 
not  only  maintain  the  patient  in  his  anemic  state,  but  may  even  drag 
him  into  serious  inanition,  and  such  an  undermined  constitution  hardly 
favors  the  speedy  healing  of  an  ulcer.  Frequent  nutrient  enemata  ex- 
cite the  gastro-intestinal  tract  into  peristaltic  activity,  and  may  thus 
induce  renewed  bleeding;  besides,  very  little  nutriment  is,  after  all, 
obtainable. 

Should  more  milk  be  given  by  mouth,  merely  enough  to  preserve  the 
body-weight — three  liters  for  an  adult — it  would  overfill  the  stomach 
and  stretch  its  walls,  thus  preventing  a  contraction  of  the  ulcer  and 
again  offering  the  danger  of  renewed  bleeding.  Lenhartz  advises 
another  dietary  treatment,  one  that  will  especially  combat  the  hyper- 
chlorhydria and  reinforce  the  enfeebled  and  anemic  state  of  the 
patient. 

The  concentrated  egg-albumen  diet  was  tried.  In  case  after  case 
the  effect  proved  so  gratifying  that  this  method  became  the  routine 
treatment.  The  sour  regurgitation  subsides,  the  vomiting  immediately 
ceases,  the  pain  and  distress  after  eating,  within  a  few  hours  to  a  few 
days,  disappears,  and  finally  an  increase  in  the  body-weight  is  manifest 


CHRONIC   GASTRODUODENAL    ULCERS  353 

as  early  as  the  first  week.  Besides,  the  improvement  is  comparatively 
rapid,  so  that  the  patient  can  be  dismissed  as  cured  within  a  briefer 
time  than  formerly. 

The  following  is  the  tabulated  regimen:  "Absolute  rest  in  bed  for 
at  least  four  weeks.  All  mental  excitement  to  be  avoided,  an  ice-bag 
being  placed  on  the  stomach  and  kept  there  almost  continually  for 
two  weeks.  This  prevents  gaseous  distention  and  promotes  contrac- 
tion of  the  stomach  walls,  thus  tending  to  obviate  hemorrhage,  and 
eases  the  pain  when  present.  On  the  first  day,  even  when  a  hemate- 
mesis  has  occurred,  the  patient  receives  between  6  and  9  oz.  (200  and 
300  c.c.)  of  iced  milk,  given  in  spoonfuls,  and  from  2  to  4  beaten  raw 
eggs  within  the  first  twenty-four  hours.  At  the  same  time  bismuth 
subnitrate  is  given  twice  or  thrice  a  day,  30  gr.  (2  grams)  per  dose,  and 
continued  for  ten  days.  The  eggs  are  beaten  up  entire  (with  a  little 
sugar) ,  and  the  cup  containing  them  is  placed  in  a  dish  filled  with  ice, 
so  that  they  remain  cold.  This  food  at  once  'binds'  the  supersecreted 
acid,  and,  therefore,  mitigates  the  pain  rapidly  and  causes  the  vomiting, 
often  quite  troublesome,  to  cease.  The  fat  which  is  present  in  the 
egg  yolk  also  inhibits  the  secretion  of  hydrochloric  acid.  The  portion 
of  milk  is  increased  daily  3  oz.  (100  c.c),  and,  at  the  same  time,  i 
additional  egg  is  given,  so  that  at  the  end  of  the  first  week  the  patient 
is  recieving  25  oz.  (800  c.c.)  of  milk  and  from  6  to  8  eggs.  Both  these 
foods  are  now  continued  in  the  same  amoimt  per  day  for  another  week. 
No  more  than  i  liter  of  milk  a  day  is  allowed  at  any  time.  Besides 
milk  and  eggs,  some  raw  chopped  meat  is  given  from  the  fourth  to  the 
eighth  day,  usually  on  the  sixth,  9  drams  (35  grams)  per  day,  in  small 
divided  doses  (stirred  up  with  the  eggs  or  given  alone) ;  the  day  after, 
18  drams  (70  grams),  and  later,  possibly  more,  if  well  digested.  The 
patient  is  now  able  to  take  some  rice,  well  cooked,  and  a  few  zwieback 
(softened) .  In  the  third  week  quite  a  mixed  diet  is  tolerated,  the  meat 
being  given  now  well  cooked  or  hghtly  broiled." 

All  heavy  foods  are  interdicted,  as  well  as  vegetables  with  husks, 
and  those  tending  to  produce  flatulence.  The  patient  is  given  strict 
orders  to  masticate  his  food  thoroughly. 

The  bowels  are  not  moved,  both  in  order  to  avoid  any  peristaltic 
irritation  and  to  permit  the  reabsorption  of  blood  that  may  have  passed 
into  the  intestine.  One  need  pay  absolutely  no  attention  to  consti- 
pation in  the  first  week,  even  in  many  cases  to  the  end  of  the  second. 
After  the  second  week  the  bowels  are  moved  with  small  glycerin  in- 
jections or  warm  water,  and  after  the  third  week  this  is  done  daily 
if  the  movement  does  not  occur  spontaneously.     After  this,  one  tries 

23 


354  CLINICAL  MEDICINE 

to  control  the  bowels  by  means  of  the  food  and  by  getting  the  patient 
to  go  to  stool  regularly. 

For  the  anemia  iron  is  given  in  the  form  of  a  soft  preparation  of 
Blaud's  pills: 

I^.      Ferri  sulphatis lo.oo  gm.; 

Magnesiae  ustae i-75  S^-'> 

Glycerini gtt.  xxx  (3.6  gm.).— M. 

Ft.  pil.  Ix. 
Sig. — Two  pills  to  be  taken  two  or  three  times  a  day. 

The  pills  are  given  as  early  as  the  sixth,  eighth,  or  tenth  day  of 
treatment,  according  to  need,  administering  them  first  in  a  macerated 
condition. 

In  severe  cases  arsenic  is  also  given  in  the  form  of  "Asiatic  pills," 
each  containing  0.000 1  gm.  of  arsenous  acid.  The  dose  is  gradually 
increased,  three  for  three  days,  four  for  four  days,  up  to  seven  for  seven 
days,  then  decreasing  again,  six  for  six  days,  etc.  After  the  tenth  day 
'  and  to  the  sixth  week,  bismuth  compositum  is  substituted  for  the 
subnitrate  and  given  three  times  a  day  before  meals.  The  patient  is 
usually  allowed  up  on  the  twenty-eighth  day  and  is  dismissed  in  the 
sixth  to  the  tenth  week.  Lenhartz  reports  only  8  per  cent,  of  recurrent 
hemorrhages  after  this  method  of  treatment,  as  compared  with  20  per 
cent,  of  the  older  methods.  No  unfavorable  results  were  produced 
(Kemp) . 

From  the  preceding  results  it  can  readily  be  inferred  that  the  treat- 
ment of  gastroduodenal  ulcers  is  both  medical  and  surgical.  The 
indications  for  surgical  treatment  are  as  follows:  "(i)  For  perforation. 
(2)  In  the  chronic  indurated  ulcer.  Experience  has  shown  that  after 
gastro-enterostomy  the  ulcer  heals  rapidly,  and  in  some  cases  the  ulcer 
itself  may  be  located.  (3)  In  all  cases  when  the  ulcer  has  caused  me- 
chanical interference  with  the  passage  of  the  gastric  contents.  (4)  In  all 
cases  associated  with  recurring  hemorrhages.  In  young  girls,  a  single 
severe  attack  of  hematemesis  may  be  a  simple  gastrorrhexis,  or  from  a 
simple  ulcer  that  heals  readily,  but  in  men  severe  hematemesis  is  al- 
most always  from  the  chronic  ulcer.  (5)  In  the  perigastric  adhesions 
after  chronic  ulcer,  operation  is  sometimes  helpful.  (6)  In  chronic  cases 
in  which  medical  treatment  fails  to  give  rehef"  (Osier). 

In  all  ulcerative  conditions  of  the  stomach  belladonna  {j  gr.  of 
the  extract)  may  be  added  three  to  four  times  per  day. 


CHRONIC    GASTRIC    DILATATION  355 

ACUTE  GASTRIC  DILATATION 

This  often  occurs  in  the  convalescence  from  the  specific  fevers,  but 
notably  from  pneumonia.  As  a  rule,  in  such  cases  the  stomach  re- 
lieves itself  by  the  vomiting  of  large  quantities  of  fluid.  It  becomes, 
however,  a  serious  condition  if  the  duodenum  is  also  involved,  when  the 
symptoms  may  be  those  of  collapse.  Thus,  such  conditions  not  un- 
commonly follow  operations,  particularly  laparotomy,  in  which  anes- 
thetics have  been  used.  Of  102  cases  collected  by  Lewis  A.  Conner, 
42  followed  operation  under  general  anesthesia. 

Treatment. — In  cases  occurring  in  convalescence  from  pneumonia 
or  other  febrile  affections,  I  have  found  great  relief  by  hypodermic  in- 
jections of  eserin,  or  the  active  principle  of  physostigma,  or  calabar 
bean  in  doses  of  -g^  gr. 

In  those  cases  that  follow  operations  with  the  use  of  anesthetics 
prompt  relief  may  come  from  the  use  of  the  stomach-tube,  with  lavage 
and  a  change  of  posture  of  the  patient  to  the  knee-elbow  position. 

CHRONIC  GASTRIC  DILATATION 

Affections  of  the  stomach  producing  dilatation  may  be  best  imder- 
stood  by  first  recalUng  what  are  the  normal  functions  of  different  parts 
of  the  stomach.  Those  parts  may  be  divided  into  three  regions:  first, 
the  fundus;  second,  the  intermediate  part ;  and  third,  the  pyloric  end. 
The  fundus  is  that  part  of  the  stomach  which  is  directly  below  the 
entrance  of  the  esophagus.  In  this  part  there  is  considerable  delay  of 
the  starchy  elements  of  food,  which  delay  allows  the  action  of  the  saliva 
mixed  with  the  food  to  produce  the  first  change  in  the  starchy  elements 
toward  the  formation  of  glucose,  which  change  is  afterward  completed 
by  the  ferments  entering  the  duodenum  from  the  pancreas  and  the 
Hver.  It  is  in  the  intermediate  portion  that  the  gastric  juice  is  secreted, 
which  contains  dilute  hydrochloric  acid  and  pepsin,  of  special  service  in 
the  digestion  of  the  protein  substances  of  the  food.  The  third  portion, 
or  the  pyloric  end,  acts  somewhat  after  the  valvular  fashion,  the  pyloric 
canal  not  dilating  until  a  certain  quantity  of  the  gastric  contents, 
formerly  called  the  chyme,  has  accumulated,  when  the  pyloric  canal 
relaxes  and  propels  the  fluids  into  the  duodenum. 

When  the  stomach  is  really  empty  it  contracts  upon  itself  and  has 
no  resemblance  to  a  cavity  such  as  is  usually  represented  in  pictures, 
but,  on  the  other  hand,  it  is  extremely  distensible,  and  in  conditions  of 
muscular  atony  of  its  walls  the  line  of  its  lower  curvature  may  fall 
much  below  the  umbilicus,  when  it  can  be  mapped  out  by  the  person 


356  CLINICAL  MEDICINE 

standing  and  swallowing  a  quantity  of  water.  Normally,  the  cir- 
cular fibers  of  its  muscular  coat  are  constantly  contracting,  so  as  to 
propel  forward  the  stomach  contents  from  left  to  right  until  they  meet 
with  the  band  which  surrounds  the  pylorus.  This  band  may  contract 
so  firmly,  as,  for  example,  during  the  act  of  vomiting,  that  the  contents 
of  the  stomach  are  shut  off  entirely  from  the  rest  of  the  alimentary 
canal.  During  digestion  a  pyloric  band  can  be  felt  in  thin  persons 
much  Hke  a  tumor,  and  its  relaxation  can  then  be  noted  by  a  sense  of 
movement  or  even  of  gurgHng  through  the  canal.  Solid  food  may 
remain  for  from  three  to  four  hours  in  the  stomach,  being  gradually 
dissolved  and  propelled  from  the  fundus  onward.  These  movements, 
however,  may  be  delayed  either  by  weakening  of  the  coats  of  the 
stomach  by  gastritis  or  by  simple  atony  of  its  walls.  In  some  cases 
of  gastritis  the  gastric  walls  still  remain  strong  enough  to  force  the 
contents  into  the  pyloric  canal.  Usually,  however,  in  these  conditions 
there  is  more  or  less  dyspeptic  disturbance  referred  to  the  epigastrium. 
In  other  cases  the  atony  is  so  pronounced  that  the  fluid  contents  ac- 
cumulate and  dilate  the  stomach  until  it  is  removed  by  the  vomiting 
of  its  contents  in  large  quantities,  which  may  then  be  considerably 
altered  in  their  nature  and  composition,  sometimes  acid  and  containing 
various  bacteria  or  fungus  growths,  such  as  the  Sarcinae  ventriculi, 
found  abundantly  in  the  vomitus  accompanying  wasting  diseases,  such 
as  tuberculosis  or  cancer.  Often,  however,  gastric  dilatation  is  caused 
by  ulcers  formed  in  the  stomach  walls,  with  the  resulting  contracting 
cicatrices  which  produce  constriction  of  the  pyloric  canal.  These 
frequently  occur  from  chronic  irritation  of  the  bile-passages  produced 
by  gall-stones,  and  also  by  cancer  developing  in  those  passages  from  a 
chronic  irritation  of  gall-stones,  but,  however  produced,  their  mechan- 
ical effect  in  contracting  the  pyloric  canal  is  to  interfere  with  the 
stomach  emptying  itself,  with  the  result  of  true  gastric  dilatation. 

Treatment. — In  all  forms  of  gastric  dilatation  the  most  efficacious 
treatment  is  by  gastric  lavage,  or  washing  out  the  stomach,  a  procedure 
which  is  by  no  means  difficult  of  execution  and,  in  fact,  is  often  resorted 
to  after  a  little  practice  by  the  patient  himself.  This  procedure  is 
best  resorted  to  in  the  morning  before  breakfast.  It  shows  its  benefits 
especially  in  conditions  of  weakening  of  the  gastric  walls  from  chronic 
gastritis,  whatever  its  origin.  It  is  often  surprising  what  quantities 
of  mucus  are  by  this  means  removed  from  the  stomach.  The  presence 
of  large  quantities  of  mucus  in  the  return  fluid  of  the  lavage  is  an  unmis- 
takable evidence  of  the  existence  of  true  gastritis,  with  its  results  of 
arresting  digestive  power  in  the  glands  of  the  stomach,  and  with  diminu- 


HYPERCHLORHYDRIA  357 

tion  in  the  antiseptic  properties  of  the  gastric  juice,  resulting  in  fer- 
mentation of  the  gastric  contents.  Repeated  lavage  of  the  stomach 
may  be  performed  every  night  on  retiring,  and  it  has  often  cured 
most  obstinate  cases  of  stomach  derangement.  Gastric  lavage,  in  fact, 
affords  great  rehef  in  such  a  grave  disorder  as  gastric  cancer  itself. 
In  this  affection  there  is  an  actual  diminution,  if  not  entire  absence,  of 
the  hydrochloric  acid  of  the  gastric  juice,  leading  ere  long  to  incurable 
ulceration  with  extravasation  of  blood,  and  with  that  decisive  symp- 
tom of  vomiting  of  "coffee-ground  fluids"  caused  by  altered  blood. 
The  cicatrization  occurring  after  ulcers  of  the  stomach  wall  may  even 
produce  a  contraction  of  its  cavity,  so  that  it  is  called  an  "hour-glass 
stomach." 

If  the  medicinal  remedies  recommended  for  the  treatment  of  gas- 
tritis and  the  employment  of  lavage  equally  fail,  a  recourse  to  surgery 
should  no  longer  be  delayed,  because  gastro-enterostomy  properly 
performed  is  often  of  the  greatest  avail  in  otherwise  hopeless  cases. 

HYPERCHLORHYDRIA 

It  is  not  often  that  glandular  tissues  secrete  more  than  is  needed 
for  their  normal  purposes.  To  this  rule  the  acid  gastric  juice  may  show 
a  striking  exception.  Cases  occur  in  which  both  the  quantity  and  the 
acidity  of  the  secretion  is  much  in  excess  of  all  requirements  for  diges- 
tion, with  consequent  discomfort  or  distress  in  the  stomach.  This  is 
because  the  gastric  secretion  depends  so  intimately  on  nervous  or  even 
on  purely  mental  states. 

This  purely  mental  effect  was  shown  in  an  experiment  by  the 
Russian  physiologist  Pawlow.  Two  dogs  were  fed  with  the  same 
quantity  of  meat  through  a  gastric  opening  in  each.  One  dog  saw  a 
piece  of  meat  hanging  before  him,  but  was  not  allowed  to  take  it.  In 
the  course  of  an  hour  and  a  half  this  dog  was  found  to  have  digested 
five  times  more  of  the  meat  in  his  stomach  than  the  other  dog  who 
meantime  saw  no  meat. 

This  dependence  of  the  acid  secretion  of  the  gastric  juice  upon 
purely  nervous  or  even  mental  stimuli  explains  the  great  variety  of 
conditions  in  which  hyperchlorhydria  is  found.  The  first  of  these  which 
we  have  mentioned  is  the  reflex  effect  produced  by  gastric  ulcers,  which 
are  notoriously  likely  to  occasion  excess  of  gastric  secretion.  Surgical 
experience  shows  that  we  can  never  be  sure,  when  the  symptoms  as- 
sociated with  hyperchlorhydria  develop,  we  may  not  already  have 
a  gastric  ulcer  present.  Another  factor  is  the  coexistence  of  neuras- 
thenic or  nervous  disorders  in  the  patients.     Thus,  chlorotic  young 


358  '  CLINICAL   MEDICINE 

women  are  peculiarly  liable  both  to  ulcer  and  to  hyperchlorhydria. 
But  hyperchlorhydria  frequently  occurs  also  among  men  who  are 
subjected  in  their  business  to  repeated  nervous  strains,  such  as  brokers 
and  speculators  in  the  money  market.  In  fact,  persons  of  both  sexes 
who  are  much  subject  to  the  worries  of  life  often  consult  the  physician 
about  symptoms  indistinguishable  from  those  found  in  the  victims  of 
functional  nervous  stomach  disorders. 

The  presence  of  gastric  hypersecretion  can  only  be  determined  by 
an  examination  of  the  stomach  contents,  such  as  a  test-meal  recom- 
mended by  Ewald.  Sometimes  this  examination  shows  that  not  only 
is  there  an  excess  of  acid  gastric  secretion  after  eating,  but  that  there 
is  a  quantity  of  acid  gastric  juice  accumulated  in  the  empty  stomach 
as  well,  to  which  the  term  "gastrosuccorrhea"  is  appHed. 

Symptoms. — The  symptoms  of  hypersecretion,  unhke  those  of 
many  cases  of  ulcer,  do  not  set  in  soon  after  a  meal,  but  usually  two 
hours  or  more  after  eating,  when  the  patients  complain  of  a  sense  of 
weight  and  then  of  distress,  if  not  of  positive  pain  at  the  epigastrium. 
This  region  may  become  quite  tender  to  pressure,  but  more  commonly 
it  is  a  diffused  soreness  which  spreads  without  definite  restriction  to 
the  left.  If  these  symptoms  continue  severe  the  patients  have  eruc- 
tations of  a  very  sour  fluid  from  the  stomach,  accompanied  by  sen- 
sations of  heart-burn  behind  the  sternum.  Vomiting  is  not  common, 
but  when  it  does  occur  it  gives  reHef.  Headaches  are  very  frequent, 
and  in  chronic  cases  there  may  be  much  depression  of  spirits.  The 
patients  rarely  show  any  failure  of  nutrition,  and  the  external  signs 
are  limited  to  those  of  the  most  woebegone  expression  of  dyspepsia. 

Treatment. — The  first  indications  of  treatment  are  to  neutralize 
the  gastric  hydrochloric  acid  by  proper  diet.  On  this  account  starches 
should  be  as  much  as  possible  excluded  or  diminished  in  quantity. 
Proteins,  on  the  other  hand,  directly  diminish  the  acidity  by  combining 
with  the  acid  contents.  Meats,  therefore,  are  indicated,  but  should 
be  cooked  in  a  way  which  would  make  them  easily  digested.  Thus, 
slightly  broiled  meats  are  easier  digested  than  when  boiled.  The 
stomach  should  never  be  overloaded  with  anything,  and  it  is  much  bet- 
ter to  have,  besides  the  ordinary  three  meals  a  day,  smaller  meals  taken 
between  times,  because  in  hyperchlorhydria  the  motility  of  the  stomach 
walls  is  often  increased,  so  that  food  is  passed  through  it  more  rapidly 
than  in  health.  It  is  striking  to  note  how  all  symptoms  or  conditions 
quickly  subside  on  taking  something  to  eat.  The  diet,  therefore, 
should  be  meats  like  mutton  chop,  moderate  slices  of  steak,  one  but 
not  two  eggs  at  a  time,  fish,  and  poultry,  taken  with  quite  crusty  bread 


HYPERCHLORHYDRIA  359 

and  butter.  On  the  other  hand,  organic  acids,  such  as  lemon  or  vinegar. 
should  be  but  sparingly  used.  Potatoes,  preferably  stewed  in  milk  and 
cut  up  fine,  will  nearly  always  agree,  and  many  persons  can  take  very 
thin  slices  of  toast  baked  again  in  the  oven.  Coffee,  as  a  rule,  is  not  well 
borne  except  when  much  diluted  with  milk.  Excessive  tea  drinking 
is  very  injurious.  Medicinally,  I  much  prefer  the  resorcin  and  the 
bichromate  pill,  recommended  previously  for  gastritis,  to  the  free  use 
of  alkalis.  The  alkahs  do  not  deal  with  the  disease,  but  only  relieve 
temporarily  the  acid  condition,  and  too  great  rehance  upon  them  may 
lead  to  actual  weakening  of  the  digestive  powers.  Much  the  best 
prescription  for  this  purpose  is  the  wineglassful  dose  of  equal  parts  of 
milk  and  lime-water,  which  may  be  taken  at  frequent  intervals.  On 
the  other  hand,  bismuth  is  of  decided  service  in  doses  of  from  lo  to  20 
gr.,  with  2  gr.  of  thymol,  after  meals  and  at  night.  I  have  found  also 
a  powder  consisting  of  10  gr.  of  subcarbonate  of  bismuth  and  10  gr. 
of  powdered  columbo,  three  times  a  day,  half  an  hour  after  meals, 
very  serviceable.  It  should  be  borne  in  mind,  however,  that  these 
patients  are  very  subject  to  constipation,  which  in  their  case  is  best 
treated  by  adding  from  i  to  2  gr.  of  powdered  rhubarb,  three  times  a 
day,  mixed  with  the  other  powders  which  they  are  taking. 

Normally,  the  stomach  is  never  empty,  for  if  it  has  no  contents  it 
then  contracts  upon  itself.  Dilatation  of  the  stomach,  therefore,  is 
always  morbid.  When  food  or  drink  enters  the  stomach,  digestion 
and  absorption  differ  in  different  parts  of  the  gastric  cavities.  The 
food,  as  a  rule,  sojourns  for  three  or  four  hours  within  the  cavity  of 
the  stomach,  the  fimdus  then  having  to  do  with  its  digestion.  The 
contents  of  the  stomach  in  the  fundus  are  effected  by  the  continuous 
action  there  of  the  saliva  mixed  with  the  food.  The  gastric  wall 
of  this  part  of  the  stomach  is  in  a  state  of  what  is  called  tone,  by 
whose  steady  contraction  the  food  is  pressed  forward  to  the  middle 
of  the  gastric  cavity,  where  it  encounters  the  acid  gastric  juice,  which 
immediately  attacks  the  protein  elements  of  food  by  its  combination 
of  the  hydrochloric  acid  with  the  enzyme  called  pepsin.  As  these 
elements  are  gradually  digested  the  liquid  product  is  propelled  to  the 
pyloric  canal  or  sphincter,  which,  at  the  end,  periodically  relaxes  and 
allows  the  acid  chyme  to  be  passed  into  the  duodenum.  It  should  be 
m,entioned  that  water  is  not  absorbed  from  the  stomach,  but  is  passed 
into  the  intestines.  Dilute  alcohol,  however,  may  be  absorbed  directly 
from  the  stomach,  but  only  a  minute  portion  of  the  saccharine  elements 
are  thus  taken  up,  the  rest  being  passed  on  to  the  duodenum.  The 
fats  are  here  not  absorbed  at  all,  but  may  be  partially  emulsified 


360  CLINICAL  MEDICINE 

during  the  gastric  movements,  but  are  more  commonly  passed  on 
unchanged  into  the  duodenum. 

ACHYLIA  GASTRICA 

Atrophy  of  the  mucous  membrane  of  the  stomach  has  its  chief 
cause  in  chronic  obHterative  gastritis,  produced  by  the  constant  swal- 
lowing of  micro-organisms  from  the  roots  of  decayed  teeth,  as  we  have 
mentioned  in  our  remarks  on  Oral  Sepsis.  This  condition  may  not  only 
involve  gastric  secretion,  but  also  intestinal  digestion  as  well.  That 
atrophy  of  the  mucous  membrane  of  the  stomach  can  occur  sponta- 
neously, as  supposed  by  Fenwick,  appears  to  me  improbable.  Exami- 
nation of  the  contents  of  the  stomach  after  a  test-breakfast  shows  the 
absence  not  only  of  the  normal  secretions,  but  equally  so  of  the  pepsin 
and  rennet.  One  of  the  results  of  such  a  state  of  the  stomach  would 
easily  be  mistaken  for  pernicious  anemia,  but  examination  of  the  blood 
shows  in  these  patients  only  the  conditions  of  severe  secondary  ane- 
mia. 

In  many  cases  achyha  gastrica  occurs  as  a  temporary  condition 
produced  by  proptosis  of  the  stomach  and  bowels,  and  may  then  be 
relieved  by  measures  proper  for  such  a  condition.  It  is  conceivable 
also  that  it  may  occur  from  chronic  nervous  derangements,  as  in  neu- 
rasthenia, and  be  reheved  by  appropriate  treatment. 

Treatment. — As  this  condition  is  characterized  by  absence  of  the 
digestive  secretions  of  the  stomach,  we  should  attempt  to  supply  the 
deficiencies  artificially  by  administering  dilute  hydrochloric  acid,  15 
drops,  with  10  gr.  of  saccharated  pepsin  at  each  meal.  The  occasional 
addition  of  2  to  3  drops  of  Fowler's  solution  of  arsenic  may  also  be 
beneficial. 

ACHLORHYDRIA  HEMORRHAGICA  GASTRICA 

The  stomach  is  often  affected  owing  to  reflex  causes.  An  example 
of  this  condition  is  -found  in  the  entire  absence  of  HCl  in  the  gastric 
juice  due  to  chronic  appendicitis.  In  other  cases  the  source  of  the 
reflex  arrest  is  from  irritation  of  gall-stones,  but,  however  induced, 
the  tendency  is  to  chronic  inflammatory  conditions  in  the  gastric 
mucosa,  which  in  chronic  cases  may  lead  to  erosions  in  the  mucous 
membranes  with  actual  hemorrhage.  This  hemorrhage  may  never 
amount  to  hematemesis,  but  may  be  found  upon  examination  of  the 
feces.  It  is  remarkable  how  long  the  symptoms  may  persist  in  some 
cases  of  chronic  appendicitis,  and  then  be  cured  by  removal  of  the  ap- 
pendix; in  other  cases  by  operations  on  the  pylorus  for  constrictions 


DIARRHEA  36 1 

caused  by  gall-stone  inflammations.  The  diagnosis  is  best  made  by- 
examination  after  a  test-meal  revealing  the  absence  of  HCl  in  the 
stomach,  and  when  the  trouble  is  evidenctly  dependent  upon  the 
chronic  appendicitis  or  cholelithiasis  these  cases  are  best  treated  sur- 
gically, as  will  be  hereafter  noted. 

Gastrostaxis. — "Under  this  name  Hale  White  describes  cases  of 
hemorrhage  from  the  stomach  in  young  girls  without  any  lesion  of  the 
mucosa.  They  are  often  mistaken  for  ulcer.  He  has  collected  29 
cases.  Surgeons  have  taught  us  that  the  condition  is  by  no  means 
uncommon.  At  operation  the  blood  has  been  seen  oozing  from 
points  in  the  mucosa.  There  may  be  no  pain  or  any  of  the  ordinary 
features  of  ulcer"  (Osier). 

FOREIGN  BODIES 

These  may  be  found  in  the  stomach  in  immense  numbers  among 
insane  persons.  Cases  have  been  reported  in  asylums  who  have  had 
to  be  constantly  watched  lest  they  should  swallow  every  variety  of 
solid  articles.  In  one  case  reported  by  Vandivert  and  Mills  from 
State  Hospital  No.  2,  St.  Joseph,  Missouri,  1446  objects  were  found. 
Neither  emetics  nor  cathartics  should  be  given  in  such  cases,  cathartics 
especially,  because  of  the  liability  to  injure  intestinal  walls  by  the 
hard  or  sharp  substances.  Usually  constipating  food,  such  as  po- 
tatoes, rice,  etc.,  should  be  taken,  in  order  to  keep  the  bowels  cos- 
tive for  a  few  days,  thus  forming  a  protective  mass  about  the  foreign 
body.  When  the  nature  and  size  of  this  accumulation  is  revealed  by 
x-ray  examination,  a  surgeon  should  be  called  in  to  perform  gastro- 
enterostomy. 

Intestinal  Disorders 
diarrhea 

In  considering  derangements  of  the  intestines  the  old  terms 
"diarrhea"  and  "dysentery"  still  hold  their  places  better  than  any 
of  the  more  recent  names  applied  to  these  disorders.  Thus,  it  is  a 
mistake  to  designate  diarrhea  an  intestinal  catarrh,  because  that  implies 
an  inflammatory  condition  in  all  cases;  whereas,  in  the  deadly  Asiatic 
cholera,  no  inflammatory  process  initiates  it,  for  inflammatory  condi- 
tions supervene,  if  at  all,  only  as  late  results  of  the  primary  infection. 
Equally  so,  dysentery  is  not  always  a  coHtis,  for  some,  and  by  no 
means  the  least  severe,  of  these  affections  involve  the  rectum  only  and 
not  the  colon. 


362  CLINICAL   MEDICINE 

The  term  "diarrhea"  is  well  defined  by  Sir  Lauder  Brunton,  who 
writes:  "The  name  diarrhea  is  properly  used  to  indicate  the  fluid  and 
too  frequent  discharge  from  the  bowels."  One  of  the  commonest 
causes  of  diarrhea  is  improper  food,  well  illustrated  in  the  ordinary 
forms  of  diarrhea  in  infants.  As  they  have  to  live  entirely  upon  milk, 
the  milk  itself  is  often  the  cause  of  their  diarrhea,  because  it  is  not 
as  well  adapted  to  their  digestive  powers  as  is  breast  milk.  We  see 
this  frequently  exemplified  in  the  difference  between  bottle-fed  and 
breast-fed  infants.  But  likewise  in  adults,  severe  diarrhea  may 
supervene  upon  partaking  of  improper  articles  of  diet. 

The  forms  as  well  as  the  nature  of  diarrhea  are  very  varied.  One 
form  is  interesting  because  it  illustrates  the  difference  between  the 
functions  of  the  small  intestine  and  those  of  the  colon.  This  is  found 
in  the  early  morning  diarrhea  of  some  patients,  who  often  have  copious 
discharges,  beginning  as  soon  as  they  wake  up  in  the  morning,  but 
ceasing  afterward,  without  troubling  them  during  the  rest  of  the  day. 
On  the  other  hand,  attacks  of  colitis  are  frequently  wholly  suspended 
by  rest  in  bed,  or  they  come  on  only  after  taking  food  or  while  walking 
about. 

Again,  looseness  of  the  bowels  may  be  caused  by  conditions  in  other 
organs,  especially  in  cirrhosis  of  the  liver  and  in  heart  disease.  Cirrho- 
sis of  the  liver  is  often  the  cause  of  very  intractable  diarrhea,  which 
is  readily  explained  by  the  venous  congestion  of  the  whole  intestinal 
tract  set  up  by  obstruction  in  the  portal  circulation.  In  the  same  way 
heart  failure  may  cause  general  congestion  of  the  intestinal  wall  and 
consequent  diarrhea.  Diarrhea  may  also  occur  in  the  course  of  specific 
fevers,  when  these  are  accompanied  by  local  ulcerative  processes,  in 
the  intestine.  This  is  illustrated  in  ulceration  of  Peyer's  patches  in 
typhoid  fever,  and  also  in  the  terminal  diarrhea  of  tuberculous  patients. 
Diarrhea  may  be  initiated  by  fermentative  changes  in  a  dilated  stom- 
ach, when  long-retained  secretions  instead  of  being  vomited  are  passed 
into  the  duodenum. 

We  shall  begin,  therefore,  with  what  may  be  properly  termed  intes- 
tinal catarrh,  due  to  the  presence  of  improper  food.  In  some  cases  this 
may  be  caused  by  too  great  an  amount  of  food  being  taken  at  one 
time  to  be  easily  digested.  As  before  remarked,  the  normal  secre- 
tions of  the  alimentary  canal  have  two  offices:  first,  digestive;  second, 
antiseptic.  When  they  fail  in  this  latter  respect,  the  food  ferments 
and  becomes  locally  irritant  to  the  intestinal  walls.  An  abundant 
secretion  thereupon  flows  from  the  intestinal  walls,  but  as  normal  ab- 
sorption is  now  delayed,  the  intestinal  contents  ferment,  and  produce 


DIARRHEA  363 

severe  irritation  of  the  mucous  membrane.  The  symptoms,  then,  in 
contrast  with  those  of  choleraic  diarrhea,  are  accompanied  with  griping 
pains,  and  in  some  cases  with  moderate  fever.  The  indication  then 
is  to  empty  the  bowel  of  its  contents,  which  may  best  be  done  by  use 
of  5  gr.  of  calomel  for  an  adult,  combined  with  30  gr.  of  compound 
jalap  powder,  after  which  action  the  diarrhea  usually  subsides.  In 
some  cases,  however,  the  irritation  of  the  mucous  membrane  does  not 
subside,  but  the  diarrhea  continues. 

Treatment. — The  best  means  then  is  to  use  a  combination  of  re- 
medial astringents  along  with  sedatives  to  diminish  the  peristalsis. 
For  this  purpose  I  have  found  a  modification  of  Hope's  mixture  very 
serviceable,  according  to  the  following  formula: 


\ aa  oiss; 


I^.      Acidi  nitrici  dil 3  iiss; 

Tinct.  camphor. 
Tinct.  opii 

Syrup  of  ginger 5  iss; 

Peppermint-water q.  s.  5vj. — M. 

Sig. — One  tablespoonful  of  this  every  three  or  four  hours. 


In  the  diarrhea  of  children  from  similar  causes  I  have  found  Dr. 
West's  prescription  much  the  most  serviceable: 

I^.     Magnesium  sulphate 3j; 

Tinct.  rhubarb 3  ij ; 

Syrup  of  ginger 3j; 

Liquor  menthae 3  v. — M. 

Sig. — Teaspoonful  three  times  a  day. 

We  have  already,  in  our  remarks  on  tj^hoid  fever,  spoken  about 
the  prevention  of  diarrhea  in  the  treatment  of  that  infectious  disease. 
This  diarrhea,  in  fact,  ought  not  to  be  allowed  to  continue,  as  it  so  de- 
pletes the  patient.  Much  of  the  emaciation,  therefore,  which  com- 
monly occurs  in  this  fever  can  be  wholly  prevented. 

Tuberculous  ulceration  of  the  intestine  may  be  very  local,  and 
then  give  rise  to  both  hemorrhage,  which  may  be  its  first  symptom, 
and  to  diarrhea.  The  danger  of  this  ulceration  is  that,  unHke  the 
ulceration  from  typhoid  fever,  it  may  produce  stenosis  of  the  intestine 
by  its  cicatrization,  which  does  not  occur  as  a  result  of  the  ulcerations 
of  typhoid  fever.  It  is  best  treated  when  there  is  hemorrhage  by  a 
pill  of  nitrate  of  silver,  opium,  and  the  resin  of  turpentine,  recom- 
mended in  the  treatment  of  hemorrhage  in  typhoid  fever.  I  never 
lost  a  patient  from  hemorrhage  in  typhoid  fever,  but,  unfortunately, 
that   did    not   prevent  subsequent  perforation;   while,  on  the  other 


364  CLINICAL  MEDICINE 

hand,  intestinal  ulcers  of  a  tuberculous  nature  but  rarely  cause  per- 
foration. The  diarrhea  which  sometimes  accompanies  the  congestion 
of  the  intestine  caused  by  weak  heart  is  best  treated  by  30-gr.  doses  of 
the  subcarbonate  of  bismuth  with  3  gr.  of  thymol,  given  three  or  four 

times  a  day. 

PERITONITIS 

The  peritoneum  is  much  the  largest  serous  membrane  in  the  body, 
and  when  all  its  folds  are  spread  out,  has  been  estimated  by  Beau 
as  four  times  the  extent  of  the  skin.  In  former  times  inflammation 
of  the  peritoneum  was  regarded  as  a  disease  by  itself,  and  was  pre- 
scribed for  accordingly.  It  is  remarkable  what  a  tolerance  for  large 
doses  of  opium  occurs  when  peritonitis  is  at  all  general,  and  I  heard 
a  distinguished  clinician  in  a  lecture  on  peritonitis  say  that  if  neces- 
sary we  should  give  100  gr.  of  opium  in  the  course  of  a  day,  and  only 
desist  upon  the  appearance  of  the  physiologic  effects  of  opium,  namely, 
contracted  pupils  and  slowness  of  breathing.  At  present  we  regard 
peritonitis  not  as  a  disease,  but  rather  more  like  a  surgical  accident, 
through  the  penetration  into  the  peritoneum  of  the  products  of  in- 
flammation or  infections  outside  its  cavity.  Thus,  one  of  the  most 
dreaded  causes  of  extensive  peritonitis  is  from  the  bursting  of  an 
abscess  into  it,  due  to  an  ulcerated  appendix. 

We  may  have  a  great  variety  of  cases  of  localized  peritonitis,  many 
of  these  being  localized  by  the  early  adhesions  which  are  formed 
between  its  two  layers.  It  should  be  remembered  that  there  is  no 
cavity  between  the  layers  of  a  healthy  serous  membrane,  for  in 
health  they  are  always  in  contact  with  each  other,  and  a  cavity  can  be 
formed  only  by  accumulations  of  gaseous  or  fluid  contents. 

Symptoms. — Some  of  the  clinical  symptoms  that  occur  in  perito- 
nitis, when  it  is  at  all  extensive,  may  be  mentioned  here.  First  its 
characteristic  pulse,  which,  besides  being  frequent,  is  small  and  of  high 
tension,  a  condition  found  in  no  other  complaint  except  scarlet  fever. 
The  decubitus  is  dorsal,  often  with  the  legs  drawn  up.  The  walls  of 
the  abdomen  are  distended,  but  well-nigh  motionless,  the  breathing 
being  thoracic.  Vomiting,  however,  occurs  and  aggravates  the  pain. 
The  gestures  of  the  patient  have  already  been  referred  to,  in  that  he 
does  not  venture  to  press  anywhere  on  the  surface  of  the  abdomen. 
The  bowels,  also,  are  obstinately  constipated,  as  their  movements 
would  only  aggravate  the  pain.  All  of  these  S5nnptoms  should  be 
remembered,  because  the  absence  of  any  of  their  chief  factors  strongly 
militates  against  the  existence  of  peritonitis.  Thus,  I  was  once  called 
in  consultation  to  see  a  lady  for  peritonitis,  because  she  complained  of 


PERITONITIS  365 

such  acute  pain  upon  the  slightest  touch  of  the  abdomen.  I  found  her 
lying  on  her  side,  and,  therefore,  pronounced  it  a  case  of  hysteria. 

Another  fact  should  be  noted,  that  not  only  are  the  muscular  walls 
of  the  abdomen  motionless,  but  they  are  also  hard  and  rigid,  this  occur- 
ring even  while  it  is  quite  local,  as  it  is  in  the  first  stages  of  appendicitis, 
when  the  localized  rigidity  may  be  mistaken  for  a  tumor.  But  these 
are  signs  which  are  common  to  inflammation  elsewhere,  as,  for  ex- 
ample, when  a  joint  is  inflamed,  Uke  the  knee,  the  muscles  supplying 
the  joint  are  contracted  and  hard,  for  the  purpose  of  keeping  the  joints 
still. 

Inflammations  of  all  the  serous  membranes  are  apt  to  produce  ad- 
hesions between  their  two  surfaces,  which  may  be  very  general,  as  in 
pericarditis,  or  extensive,  as  in  pleuritis.  The  most  striking  example, 
however,  of  localized  adhesions  occurs  in  the  peritoneum.  Thus,  in 
cirrhosis  of  the  liver,  even  though  there  be  much  ascites,  which  might 
be  expected  to  separate  the  two  layers,  yet  after  death  we  often  find 
the  coils  of  the  intestine  partially  matted  together  in  numerous  places. 

Adhesions  of  serous  membranes  due  to  their  inflammations  must 
be  regarded  as  a  very  important  defensive  means  of  nature  to  prevent 
what  would  otherwise  be  a  fatal  extension  of  the  inflammation.  Thus, 
gastroduodenal  ulcers  are  usually  prevented  from  causing  general 
peritonitis  by  the  early  formation  of  peritoneal  adhesions  at  their  sites, 
and  what  is  true  of  these  lesions  is  also  the  case  elsewhere  in  the  abdo- 
men. It  is  rare,  therefore,  to  find  at  autopsy  a  peritoneum  completely 
free  from  adhesions.  Fatal  peritonitis,  therefore,  must  be  due  to  the 
virulence  of  the  infecting  organism  overcoming  the  local  defensive 
processes  of  the  system.  In  some  cases  this  virulence  is  great  enough  to 
prevent  the  ordinary  symptoms  of  inflammation.  I  knew  an  eminent 
physician  of  New  York,  whose  death  could  not  be  accounted  for,  until 
at  autopsy  he  was  found  to  have  suffered  from  a  general  peritonitis, 
without  any  of  the  ordinary  symptoms. 

Such  cases  of  virulent  infections  of  the  peritoneum  with  but  few 
signs  of  inflammation  are  common  in  the  most  dangerous  form  of  gen- 
eral peritonitis  occurring  in  parturient  women,  and  which  formerly 
went  by  the  name  of  puerperal  fever.  The  infection  here  occurs  by 
one  of  two  roots,  either  by  the  Fallopian  tubes,  as  they  open  free  on 
the  peritoneal  surface,  or  by  the  lymphatics  proceeding  from  an  in- 
fective and  sometimes  putrid  focus  in  the  cavity  of  the  uterus.  This 
puerperal  infection  is  usually  very  rapid  in  its  course,  death  occurring 
within  a  week,  commonly  setting  in  by  rigors  and  grave  s)miptoms  of 
constitutional  character,  but  in  severe  epidemic  forms  it  might  run 


366  CLINICAL  MEDICINE 

its  course  with  a  few,  if  any,  clinical  symptoms  of  peritonitis,  the 
temperature  rising  to  105°  or  106°  F.,  when  death  often  occurs  with 
symptoms  of  syncope. 

Since  the  nature  of  this  terrible  malady  has  been  demonstrated, 
modern  medical  science,  by  measures  of  prophylaxis,  has  made  so- 
called  puerperal  fever  well-nigh  extinct,  as  we  have  shown  at  the  close 
of  our  article  on  Erysipelas. 

Treatment. — The  treatment  of  peritonitis,  of  course,  depends  upon 
its  origin,  which,  as  we  have  remarked,  is  nearly  always  of  a  surgical 
kind.  When,  as  in  cases  of  appendicitis,  an  abscess  has  formed,  this 
should  be  not  only  immediately  evacuated,  but  so  far  as  possible  the 
affected  parts  should  be  thoroughly  cleansed  by  douches  of  water  at 
100°  F.  Some  remarkable  recoveries  have  been  reported  by  this 
measure  after  the  peritonitis  has  extended  to  quite  distant  parts  of  the 
membrane.  When  the  source  is  within  the  pelvic  cavity  the  indica- 
tions are  still  the  same,  although  the  measures  may  have  to  be  modified 
according  to  conditions  present  in  the  organs  involved.  No  purulent 
collection  can  ever  be  safely  left  to  itself  in  the  body,  but  must  be 
evacuated  and  its  cavity  drained. 

Medicinally,  we  should  have  recourse  to  opium,  as  already  men- 
tioned, but  it  should  be  remembered  that  opium  in  such  conditions 
does  not  aQt  by  its  sedative  properties,  but  rather  by  its  great  stimu- 
lant effects  on  the  heart.  Owing  to  the  relation  of  the  abdominal 
cavity  to  general  vitality,  as  we  have  already  mentioned,  abdominal 
affections  and,  notably,  peritonitis  immediately  depress  the  heart,  and 
against  this  depression  we  have  no  remedy  equal  to  free  doses  of  opium. 

Tuberculous  peritonitis  we  have  already  referred  to. 

Peritonitis  in  children  generally  occurs  from  the  same  causes  as  in 
adults,  particularly  from  tuberculosis,  as  we  have  already  mentioned. 
Cirrhosis  of  the  liver  we  have  also  spoken  of  as  occurring  in  child- 
hood, and  such  patients  may  require  frequent  tapping.  In  after-life 
the  coexistence  of  ascites  with  jaundice  is  very  suggestive  of  cancer 

of  the  liver. 

ASCITES 

Ascites,  or  accumulation  of  fluid  in  the  cavity  of  the  peritoneum  is 
a  very  common  accompaniment  of  cirrhosis  of  the  liver,  particularly 
of  its  atrophic  form.  Like  the  mechanism  of  edema  in  general,  it  is 
not  easy  to  explain  in  every  case  the  mechanism  of  the  productions  of 
ascites.  Owing  to  the  effects  of  mechanical  pressure  which  it  occa- 
sions, there  may  be  interference  with  the  functions  of  the  kidneys. 
Usually  it  differs  from  progressive  anasarca  in  either  valvular  affec- 


INTESTINAL    MOTILITY  367 

tions  of  the  heart  or  from  parenchymatous  nephritis,  in  that  it  does 
not  produce  dropsy  of  the  lower  extremities,  but,  however  caused,  we 
are  often  obUged,  owing  to  its  mechanical  effects,  to  tap  the  abdomen 
and  draw  the  fluid  off.  This  should  be  done  with  the  patient  sitting 
on  the  edge  of  the  bed,  having  previously  appUed  a  broad  abdominal 
binder,  to  be  drawn  tighter  as  the  fluid  escapes,  otherwise  fatal  syncope 
might  occur  from  a  too  rapid  emptying  of  the  distended  abdomen. 
Previous  to  introducing  the  trocar  the  skin  should  be  carefully  disin- 
fected, because  otherwise  the  wound  may  be  infected  and  erysipelas 
occur. 

Treatment. — In  all  cases  of  cirrhosis  of  the  liver,  tapping  should  be 
resorted  to  early,  because  not  infrequently  the  patient  may  remain 
for  a  number  of  weeks  without  needing  a  repetition  of  the  operation. 

INTESTINAL  MOTILITY 

There  is  no  commoner  affection  of  the  intestine  than  alterations 
in  its  peristaltic  movements.  Such  changes  may  forcibly  illustrate  the 
remarkable  association  of  the  nerves  throughout  the  whole  intestinal 
tract. 

Thus,  dysenteric  irritation  of  the  rectum  may  cause  relaxation  of 
the  pylorus,  with  rapid  emptying  of  the  stomach  into  the  duodenum,  and 
so  on  through  the  entire  intestinal  canal,  especially  in  children,  so  that 
they  become  starved  to  death,  for  not  a  particle  of  food  can  enter  the 
stomach  without  its  being  quickly  discharged  at  the  anus.  The  little 
patients  rapidly  emaciate,  and  have  an  aged  and  withered  appearance. 
The  proper  treatment  of  these  patients  is  by  enemata  of  laudanum 
without  any  starch,  carefully  graded,  however,  to  the  age  of  the  patient, 
for  children  are  very  susceptible  to  opium.  The  reHance,  however, 
must  be  mainly  upon  the  enemata  of  bromid  of  potassium,  which  may 
be  given  in  from  5-  to  lo-gr.  doses.  This  is  due  to  the  fact  that  the 
bromids  are  the  most  efficient  of  all  agents  in  allaying  reflex  excitabil- 
ity. Milk  should  be  avoided,  and  instead  finely  scraped  raw  meat 
should  be  given  in  half-teaspoonful  doses  every  half-hour. 

These  facts  are  also  illustrated  by  the  marked  clinical  contrasts 
between  dysentery,  which  is  an  affection  of  the  colon,  and  diarrhea. 
In  many  cases  of  diarrhea  among  adults  due  to  affection  of  the 
small  intestine,  the  bowel  movements  do  not  occur  during  the  night, 
and  only  early  in  the  morning.  When  the  lower  part  of  the  colon  is 
affected,  however,  the  movements  occur  directly  after  eating,  and 
thus  constitute  a  valuable  clinical  sign  of  the  existence  of  dysenteric 
colitis.     Sometimes  in  these  cases  the  patients  can  recognize  in  the 


368  CLINICAL  MEDICINE 

stools  small  particles  of  food  which  they  have  just  taken.  In 
not  a  few  instances  of  this  kind  an  ulceration  is  present  in  the  lower 
bowel,  and  often  can  be  found  on  inspection  with  a  proctoscope.  It 
is  striking  to  find  how  these  ulcerations  may  follow  as  a  chronic 
result  supervening  upon  an  acute  coHtis,  occurring  while  the  patient 
was  in  a  warm  climate,  and  then  remaining  to  torment  him  for  years 
by  the  occurrence  of  local  ulceration  in  the  neighborhood  of  the  rectum. 
It  is  also  in  these  cases  that  general  infection  of  the  blood  by  the  en- 
trance of  the  Bacillus  coH  is  so  common,  as  before  remarked. 

Constipation. — The  supervention  of  deficient  movement,  leading  to 
constipation,  is  so  common  that  the  physician  is  oftener  consulted 
about  sluggishness  of  the  bowels  than  almost  any  other  infirmity. 
It  should  be  borne  in  mind  that  the  only  natural  remedy  for  constipa- 
tion is  cellulose,  so  largely  present  in  all  vegetables.  This  is  illus- 
trated in  nature  by  the  difference  between  carnivora,  who  do  not  have 
loose  movements,  and  herbivora,  who  are  never  long  without  semifluid 
passages.  But  herbivora  are  never  condemned  to  a  sedentary  life, 
and  it  is  due  to  the  want  of  assistance  by  the  movements  of  the  ab- 
dominal muscles  that  constipation  so  frequently  occurs  in  the 
people  of  civiUzed  communities.  On  that  account  the  relief  of  habitual 
constipation  is  no  easy  matter,  for  it  may  call  for  a  permanent  change 
in  Hfe  habits.  Perhaps  one  of  the  most  effective  agents  for  restoring 
normal  action  of  the  bowels  is  horseback  riding,  but  this  remedy  is  so 
unattainable  except  by  a  very  few,  that  we  must  deal  with  this  com- 
plication as  best  we  may.  First,  by  insisting  upon  perfect  regularity 
in  attending  to  the  bowel  movements.  The  most  natural  time  for 
the  bowels  to  be  evacuated  is  just  after  food  has  been  taken  following  the 
longest  fast.  If,  therefore,  patients  would  resort  each  day  at  exactly 
the  same  time  (by  the  watch)  after  breakfast,  this  of  itself  would  fre- 
quently result  in  curing  the  difficulty,  because  of  the  important  role 
of  habit  in  all  functions,  but  especially  in  the  functions  of  the  intesti- 
nal canal.  But  we  must  resort  to  many  other  ways,  chief  of  which 
should  be  the  regulation  of  the  diet.  For  this  purpose  the  use  of 
fruits  is  invaluable,  as  they  contain  so  much  cellulose.  An  orange 
and  a  banana,  taken  at  breakfast  with  a  tumblerful  of  water  before  any 
other  food,  are  often  quite  efficacious.  Prunes  are  a  favorite  article  with 
many,  but  some  persons  find  that  they  disturb  the  digestion.  The 
frequent  employment  of  figs  has  the  disadvantage  that  the  seeds  may 
accumulate  in  large  masses.  Medicinal  laxatives  of  all  kinds  are  to 
be  deprecated,  for  while  some  of  them,  like  preparations  of  cascara,  are 
effective,  the  intestine  soon  becomes  accustomed  to  them,  so  that  the 


ENTEROPTOSIS  369 

constipation,  in  the  long  run,  is  worse  than  before.  Salines,  on  the 
other  hand,  relieve  the  bowels  with  the  least  expenditure  of  the  pa- 
tient's strength.  A  good  prescription  is  a  dram  of  sulphate  of  mag- 
nesium with  I  gr.  of  quinin,  taken  in  a  tumblerful  of  water  on  rising. 
Another  good  laxative  is  found  in  a  prescription: 

I^.     Compound  extract  of  colocynlh 3  j; 

Extract  of  belladonna gr.  v; 

Liquor,  potassa; 5  ss; 

Pulv.  glycerrhiz q.  s.       — M. 

Ft.  pil.  XX. 
Sig. — One  to  be  taken  at  night. 

A  nostrum  of  a  vegetable  substance  imported  from  Germany  and 
called  "regulin"  has  proved  very  beneficial  in  securing  natural,  but 
not  laxative,  movements.  It  is  somewhat  troublesome,  however,  in 
requiring  that  it  should  be  administered  in  teaspoonful  doses  on  some 
cereal  with  milk  on  rising  and  at  night. 

ILEUS 

This  is  a  form  of  obstruction  of  the  bowels  which  is  not  due  to 
an  organic  cause.  I  once  had  a  remarkable  case  of  the  kind,  which  I 
published  in  the  "Transactions  of  the  New  York  State  Medical  Society," 
in  a  young  woman  who  was  caught  in  a  cold  thunder  shower  while 
menstruating.  This  stopped  her  menses  and  at  the  same  time  caused 
the  most  obstinate  constipation,  along  with  such  borborygmi  or  rimi- 
blings  of  the  intestine  that  they  could  be  heard  across  the  room.  When 
the  bowels  were  at  last  moved  by  a  strong  cathartic,  the  movement 
showed  not  a  trace  of  ordinary  pigment,  but  looked  like  lime  plaster. 
Not  long  afterward  she  had  copious  stercoraceous  vomiting.  After  a 
time  the  urine  suddenly  stopped,  whereupon  the  saHva  and  the  tears 
iDCgan  to  flow  very  copiously.  On  testing  the  saliva  with  strong  HNO3, 
crystals  of  nitrate  of  urea  appeared,  showing  that  the  parotids  were 
taking  on  the  role  of  the  kidneys.  This  vicarious  action  of  the  parotids 
and  kidneys  continued  to  alternate  at  intervals  of  less  than  a  week 
for  a  period  of  four  months,  until  she  died.  Postmortem  the  mucous 
membrane  of  the  intestine  was  extraordinarily  atrophied,  showing  little 
trace  of  normal  glandular  tissue. 

ENTEROPTOSIS 

When  one  considers  the  number  and  the  variety  of  the  abdominal 
organs,  on  the  one  hand,  and  the  flexibiHty  of  the  structures  forming  the 
abdominal  walls,  on  the  other,  it  is  no  wonder  that  displacement  of 
24 


370  CLINICAL   MEDICINE 

abdominal  organs  is  so  common.  Often  such  displacement  is  normal, 
occurring  during  the  movements  of  respiration,  and  equally  so  in  those 
of  digestion.  Moreover,  in  women  the  growth  of  the  pregnant  uterus 
occasions  more  displacement  of  the  adjoining  parts  than  would  be 
possible  in  any  other  cavity  in  the  body.  The  particular  displace- 
ment which  forms  the  subject  of  this  article  may  include  a  falhng 
downward  of  the  stomach  or  the  intestines,  especially  of  the  transverse 
colon,  and  often  of  the  kidneys,  until  they  are  packed  into  the  cavity 
of  the  pelvis.  It  can  readily  be  imagined,  therefore,  what  a  variety 
of  symptoms — motor,  sensory,  and  secretory — may  have  their  origin  in 
prolapse  of  these  organs,  and  which  can  be  cured  only  by  mechanical 
measures  which  will  restore  the  displaced  viscera  to  their  normal 
positions. 

Enteroptosis  may  exist  in  a  marked  degree  without  producing  any 
symptoms.  Usually,  however,  there  is  a  variety  of  gastric  derange- 
ments grouped  under  the  term  "dyspepsia,"  or  intestinal  symptoms  of 
various  kinds,  constipation  being  very  common,  with  stasis  of  the 
intestinal  contents,  and  a  number  of  nervous  symptoms  directly  trace- 
able to  auto-iritoxication.  Local  symptoms  also  may  be  caused  by 
dragging  of  the  prolapsed  viscera  upon  their  attachments.  Among 
these  may  be  mentioned  displaced  or  movable  kidneys,  which  would 
best  be  treated  in  the  chapters  on  Renal  Disorders. 

All  this  proves  the  importance  of  early  diagnosis  of  this  condition, 
which  may  be  readily  demonstrated  on  inspection  of  the  abdomen. 
Wholly  different  from  the  normal,  there  is  a  transverse  depression 
extending  across  the  abdomen,  this  depression  usually  being  noticeable 
between  the  ensiform  and  the  umbilicus.  On  the  other  hand,  below 
the  umbihcus  there  is  a  protrusion  of  the  abdominal  walls  to  which 
the  term  "pot-belly"  has  been  applied.  Closer  inspection  will,  in 
thin  persons,  show  that  the  lesser  curvature  of  the  stomach  is  on  a 
line  with  or  even  below  the  umbihcus.  In  the  dorsal  position  the  vis- 
cera fill  both  flanks.  The  lower  curvature  of  the  stomach  can  then 
be  mapped  out  by  percussion  when  a  quantity  of  fluid  has  just  been 
taken,  and  this  may  be  further  demonstrated  by  eHciting  a  splashing 
sound  through  the  means  technically  called  "clapotage." 

In  other  derangements  enteroptosis  is  sure  to  aggravate  displace- 
ments of  the  uterus  and  ovaries,  with  corresponding  symptoms. 

Treatment. — In  no  other  set  of  disorders  is  the  principle  so  illus- 
trated that  derangements  of  a  mechanical  sort  are  best  treated  by 
mechanical  means.  After  the  prolapsed  viscera  have  been  restored 
to  their  normal  positions,  they  should  be  kept  there  by  external  sup- 


ENTEROPTOSIS 


371 


ports.  For  this  purpose  all  bandages  are  useless,  and  in  their  places 
adhesive  plaster  should  be  used.  Far  the  best  of  these  contrivances 
is  the  belt  devised  by  Dr.  Achilles  Rose,  which  will  be  described  later. 
I  have  known  patients  who  have  been  so  reduced  that  they  were  un- 
able to  attend  to  their  ordinary  duties  of  life  with  general  impair- 
ment of  health  and  nutrition  who  were  restored  by  the  employment 
of  Rose's  belt  to  a  condition  of  excellent  health. 
Kemp  describes  Rose's  belt  as  follows: 


Fig.  I. — Pattern  for  cutting  the  Rose  plaster  abdominal  binder:  Dotted  lines  for  section. 


Fig.  2. — Pattern  for  cutting  the  Rose  plaster  abdominal  binder:  Plaster  after  section. 


"Adhesive  plaster,  zinc  oxid  on  soft  moleskin  (Johnson  and  Johnson), 
preferably  7  inches  wide,  though  6  inches  can  be  employed.  A  yard 
in  length  will  suffice  in  most  cases.  The  circumference  of  each  patient 
should  be  measured,  and  the  plaster  should  be  long  enough  to  encircle 
the  waist.  The  plaster  is  folded  over,  so  that  the  free  ends  are  in  Hne, 
and  a  curved  line  drawn  in  pencil  from  the  lower  margin  of  the  point 
where  it  folds  to  the  free  margin,  to  about  i  inch  below  the  upper 
border.  The  plaster  is  cut  along  this  line,  giving  three  pieces;  or  the 
plaster  is  stretched  out  and  the  dotted  lines  marked,  as  in  Fig.  i ,  and 
cut  along  these  lines,  giving  three  pieces,  I  and  the  two  lateral  pieces, 
//  and  ///,  as  in  Fig.  2. 

"7  is  applied  to  the  abdomen,  and  the  lateral  pieces,  and  III, 
overlap  in  front  and  are  applied  to  the  under  plaster.  These  serve  to 
draw  up  the  abdomen. 

"To  avoid  irritation  of  the  umbiHcus  I  cut  a  V  out  of  the  upper 
border  of  the  under  plaster  or  invert  a  small  portion  of  it.  The  sharp 
angle  below  should  be  cut  off  to  avoid  interference  with  the  pubic  hair. 
The  curved  portions  of  the  lateral  wings  should  look  upward  and 
somewhat  inward  and  adhere  to  the  lower  ribs.     The  sharp  angles  of 


372 


CLINICAL   MEDICINE 


the  lateral  wings  at  the  symphysis  may  also  be  cut  off  to  avoid  the 
hair. 

''Hair,  if  present  on  the  abdomen,  is  shaved,  and  the  surface  cleaned 
with  ether  or  chloroform. 

"The  plaster  is  appHed  with  the  patient  in  the  dorsal  position  and, 
preferably,  with  hips  shghtly  elevated. 

"The  plaster  should  remain  on  for  four  to  six  weeks,  depending  on 
the  season  of  the  year,  irritation  (which  is  rare),  or  its  loosening.  It 
should  then  be  removed,  a  full  bath  given,  talcum  dusted  on,  and 
twenty-four  hours  later  a  new  belt  applied. 

"Oil  of  wintergreen,  appHed  to  adhesive  plaster,  aids  its  easy  and 
painless  removal.  One  can  also  apply  to  the  plaster  a  lo  per  cent, 
wintergreen  oil  ointment  (Beardsley,  'Jo^^.  Amer.  Med.  Assoc.,' 
Jan.  28,  1911). 

"One  patient  sent  me  by  Wm.  H.  Thomson,  a  severe  case  of  splanch- 
noptosis, wore  the  belt  fourteen  months,  gained  40  pounds  in  weight, 
and  was  completely  cured. 

"The  device  gives  brilliant  results.  The  method  of  support  by  a 
pad  for  the  special  organ  is  unscientific. 

"Only  on  occasions  when  the  material  for  Rose's  belt  was  not  at 
hand  have  I  apphed  a  method  with  narrow  strips  of  plaster.  They 
overlap  at  the  linea  alba  in  front  and  at  the  spine  behind.  As  the  final 
procedure,  two  transverse  strips  are  applied  in  front." 

INTESTINAL  DISCHARGES 

We  may  make  here  a  few  observations  upon  the  bacteriology  of 
the  intestinal  tract.  Enormous  numbers  of  bacteria  normally  occupy 
the  intestinal  tract  of  man  and  animals.  A  conception  of  the  number 
may  be  gained  from  the  knowledge  that  Strassburger  has  found  in 
accurate  investigations  that  one-third  of  the  weight  of  the  dry  residue 
of  the  feces  consists  of  the  bodies  of  dead  bacteria.  Strassberger  has 
estimated  the  daily  output  at  128,000,000,000.  Billroth  stated  that 
there  are  more  bacteria  in  the  large  than  in  the  small  bowel.  Sys- 
tematic examinations  show  progressive  increase  in  number  from  the 
duodenum  to  the  large  intestine.  The  duodenum  and  jejunum  may  be 
entirely  free  six  hours  after  meals.  Under  ordinary  conditions  the 
bacteria  of  the  feces  are  practically  all  dead.  The  cause  of  this  actual 
sterilization  of  the  feces  has  not  yet  been  determined.  In  morbid 
conditions  of  the  bowel,  however,  all  this  may  be  changed,  and  there 
is  no  doubt  that  many  states  of  disease  are  due  to  the  activity  of  Hving 
organisms  which  are  always  found  normally  in  the  intestinal  tract, 


INTESTINAL    DISCHARGES  373 

as  we  have  demonstrated  in  our  chapter  on  Infections  by  the  Bacillus 
Coli. 

First,  with  reference  to  the  diarrhea  of  children,  caused  in  the 
first  instance  by  unwholesome  food,  the  most  common  forms  are  due 
to  actual  infection  of  the  milk  by  a  group  of  organisms  closely  similar 
or  identical  with  the  bacillus  isolated  by  the  Japanese  bacteriologist, 
Shiga.  This  has  been  proved  by  the  researches  of  the  workers  in  the 
Rockefeller  Institute  of  New  York,  such  as  Flexner,  Hiss,  and  others, 
who  demonstrated  the  connection  of  this  bacillus  with  common  sum- 
mer diarrhea,  loosely  grouped  under  the  head  of  cholera  infantum. 
This  organism  attacks  the  lower  bowel,  producing  distinctly  dysenteric 
symptoms,  although  at  the  beginning  persistent  vomiting  may  be 
present.  When  it  is  remembered  how  Asiatic  cholera  may  be  com- 
municated by  the  most  insignificant  addition  of  the  organism  to  articles 
of  food,  the  occasional  occurrence  of  Shiga's  bacillus  in  the  discharges 
from  breast-fed  children  may  be  easily  accounted  for,  as  the  majority 
of  these  patients  is  to  be  found  in  the  crowded  tenements  of  the  poor 
in  large  cities.  The  best  preventive,  therefore,  is  by  boiling  the  milk, 
which  destroys  the  pathogenic  organisms. 

Next  to  disorders  of  motility  come  derangements  of  intestinal 
secretions.  These  are  very  varied,  both  in  their  nature  and  in  their 
causation. 

The  simplest  of  these  are  those  fluxes  due  to  the  presence  of  un- 
wholesome food.  This  is  fully  illustrated  in  the  diarrhea  of  children. 
The  digestive  powers  of  infants  are  relatively  so  feeble  that  their  death- 
rate  in  the  first  year  is  the  highest  of  any  subsequent  year  of  life.  This 
is  because  their  mother's  milk  is  their  only  natural  food,  and  the  mor- 
tality of  bottle-fed  infants  is  a  proof  of  this.  Even  after  dentition  is 
completed  the  bowels  of  children  are  still  easily  deranged  by  improper 
feeding. 

But  the  subject  of  diet  is  an  important  one  at  all  ages,  because  the 
commonest  forms  of  diarrhea  among  adults,  whether  acute  or  chronic, 
are  frequently  best  treated  by  finding  out  what  kind  of  food  is  most 
suited  for  the  patients. 

Yet  many  intestinal  fluxes  have  nothing  to  do  with  food.  First 
among  these  we  would  rate  infections  such  as  yellow  fever  and  Asiatic 
cholera,  already  spoken  of,  as  good  examples.  Thus  the  poison  of  the 
cholera  vibrio  appears  to  paralyze  the  solar  plexus,  for  the  blood  is 
then  drained  of  its  serum  through  the  bowels,  much  as  an  animal 
dies  following  experimental  extirpation  of  the  solar  plexus. 

Other  forms  of  diarrhea  follow  infections  causing  intestinal  ulcera- 


374  CLINICAL  MEDICINE 

tion,  as  in  typhoid  fever  and  tuberculosis.  Both  hemorrhage  and  per- 
foration of  the  intestinal  wall  are  apt  to  accompany  these  lesions. 

Obstructions  in  the  portal  circulation  by  cirrhosis  of  the  Uver  may 
cause  a  wholly  unmanageable  intestinal  flux. 

Instead  of  this,  we  may  have  death  occur  unexpectedly  from  hemor- 
rhage. I  knew  of  a  case  of  cirrhosis  in  which  all  the  blood  of  the  body 
seemed  to  be  poured  into  the  intestine  without  any  of  it  being  voided 
outside.  Blood-poisoning  in  Bright's  disease  may  also  destroy  life 
by  fatal  diarrhea,  and  it  is  one  of  the  terminal  symptoms  of  this  com- 
plaint to  have  these  bowel  discharges  bloody. 

We  prefer,  therefore,  to  speak  of  these  various  affections  as  disor- 
ders of  intestinal  secretion  rather  than  under  the  heading  of  Catarrhal 
Enteritis,  for  many  of  these  affections  are  in  no  way  associated  with 
inflammatory  processes. 

One  form  of  diarrhea  in  children,  spoken  of  under  the  term  of 
"enterocolitis,"  is  easily  controlled  by  medicines  unless,  if  neglected,  the 
colitis  finally  takes  the  form  of  dysentery.  At  one  time,  many  years 
ago,  I  had  charge  of  the  children's  class  in  a  leading  city  dispensary. 
This  class  grew  so  much  in  numbers  that  the  original  quarters  had  to 
be  enlarged,  and  was  crowded  by  mothers  bringing  their  children 
with  what  would  now  be  termed  "enterocolitis."  The  infants  were  so 
commonly  relieved  by  a  prescription  which  I  copied  from  West's 
"Diseases  of  Children"  that  I  finally  gave  the  prescription  to  the 
exclusion  of  numerous  others  given  in  that  book  on  the  treatment  of 
diarrhea.     This  prescription  was: 

I^.      Magnesii  sulphatis 3 j; 

Tincturse  rhei 3ij; 

Syr.  zingiberis 3 j; 

Aquse  menthse 3vj. 

Dose. — Teaspoonful  every  three  hours  for  an  infant  one  year  old.     For  children  from 
two  to  three  years  old  the  proportions  of  magnesium  and  rhubarb  to  be  doubled. 

In  many  cases  of  diarrhea  of  adults  caused  by  improper  food  a 
composition  of  rhubarb  and  magnesia  is  often  of  the  highest  service. 

CHOLERAIC  DIARRHEA 

Much  the  most  serious  of  diarrheas  is  the  choleraic.  It  is  almost 
exclusively  an  affection  of  the  small  intestine  in  its  origin  and  course, 
and  quite  distinct  in  its  symptoms  from  affections  of  the  colon.  In 
some  cases  of  choleraic  diarrhea  the  upper  part  of  the  large  intestine 
may  become  involved  by  extension,  so  that  a  true  colitis  may  supervene, 


CHOLERAIC    DIARRHEA  375 

but  this  does  not  alter  the  fact  that  originally  no  choleraic  diarrhea 
begins  as  a  colitis. 

The  grave  feature  in  all  choleraic  diarrhea  is  the  tendency  of  the 
profuse  watery  discharges  to  drain  the  blood  of  its  serum,  so  that  in 
this  sense  the  patient  may  bleed  to  death.  Thus,  in  severe  forms  of 
cholera  nostras  or  cholera  morbus  the  clinical  features  may  be  indis- 
tinguishable from  those  of  Asiatic  cholera  itself,  the  only  difference 
being  that  the  latter  occurs  as  an  epidemic,  while  the  former  is  sporadic 
and  does  not  show  the  same  bacteriology. 

Clinically,  cholera  infantum  is  likewise  as  true  a  choleraic  affec- 
tion as  the  Asiatic  pestilence  itself,  and  with  the  same  consequences. 

Choleraic  diarrhea  occurs  neither  spontaneously  nor  from  blood- 
poisoning,  but  always  from  irritation  of  the  intestinal  wall  by  food 
which  is  improper  in  quality  or  in  quantity.  It  begins,  therefore,  with 
symptoms  of  local  irritation,  causing  cramps  or  colicky  pains.  Soon 
inflammatory  changes  occur  in  the  intestines,  accompanied,  in  children, 
by  fever,  which  may  range  from  103°  to  105°  F.  As  we  have  remarked, 
serious  organic  changes  may  occur  in  thoracic  viscera  without  caus- 
ing alarm,  but  the  moment  the  abdominal  viscera  are  affected,  if  only 
by  functional  derangements,  the  face  wears  a  woebegone  expression. 
So  the  first  experience  puts  an  end  to  all  cheerfulness,  for  soon  both 
nausea  and  vomiting  set  in.  One  of  the  commonest  difficulties  in  the 
treatment  of  choleraic  derangements  is  that  the  stomach  refuses  to 
retain  anything. 

But  the  chief  element  in  the  complaint  is  the  profuse  diarrhea. 
At  first  the  bowel  is  emptied  of  its  more  or  less  soHd  content,  which 
may  have  a  very  offensive  odor,  but  soon  the  discharges  become 
watery,  and  in  some  instances,  particularly  in  children,  tinged  with 
blood.  The  purely  watery  discharges  are,  like  the  blood-serum,  al- 
kaline in  reaction. 

In  choleraic  diarrhea,  whether  in  adults  or  in  children,  painful 
muscular  cramps  occur,  shown  in  infants  by  the  clutching  of  the 
fingers  and  carpopedal  contractions  of  the  feet.  Soon  in  children 
nervous  sjnnptoms  supervene,  like  drowsiness  or  of  coma.  These  are 
not  necessarily  toxic,  but  are  dependent  upon  interference  of  the 
cerebral  blood-supply.  Sometimes,  however,  such  symptoms  are 
truly  uremic.  It  should  be  remembered  that  the  kidneys  become 
severely  affected  in  all  cases  of  profuse  choleraic  diarrhea,  as  they  do 
in  Asiatic  cholera.  On  that  account,  every  attack  of  cholera  morbus 
in  an  elderly  person  should  be  promptly  followed  by  an  examination  of 
the  condition  of  the  kidneys,  otherwise  the  patient  may  soon  die  of 


376  CLINICAL  MEDICINE 

uremia.  The  best  remedy,  then,  is  to  have  the  bowels  irrigated  by 
4  to  6  gallons  of  hot  normal  saline  solution,  and  urotropin  and  sodium 
benzoate  administered  as  against  the  Bacillus  coh  infection  of  the 
kidneys. 

It  is  curious  that  if  a  person  has  been  once  attacked  with  cholera 
morbus  after  indulging  too  freely  in  some  favorite  article  of  food,  he 
ceases  thereafter  to  wish  any  return  to  such  eating.  I  knew  one  per- 
son who  was  very  fond  of  muskmelons,  until  one  night  he  ate  too  many 
of  them,  when,  after  the  painful  experience  which  followed,  he  could 
not  indulge  in  muskmelons  for  many  years.  The  stomach  is  an 
unchristian  organ  and  slow  to  forget  its  resentments. 

Treatment. — We  begin  with  the  treatment  of  cholera  infantum 
because  the  urgency  of  the  symptoms  calls  for  very  prompt  action. 
The  first  thing  to  do  is  to  administer  hypodermically  that  most  trust- 
worthy of  heart  stimulants,  camphor  dissolved  in  sterilized  almond  or 
olive  oil.  As  much  as  3  to  5  gr.  of  camphor  should  be  administered, 
and  repeated  in  two  hours  if  necessary.  The  next  is  to  irrigate  the 
bowel  by  means  of  a  fountain  syringe  and  thoroughly  wash  out  the 
bowel  with  2  to  3  gallons  of  normal  saline  solution.  This  often  pro- 
duces a  marked  change  for  the  better  in  the  baby.  If  vomiting  per- 
sists, lavage  of  the  stomach  should  then  follow,  and  at  the  end  of  this 
a  drop  dose  of  Fowler's  solution  in  water  should  be  given.  It  is  curious 
for  how  long  particles  of  the  offending  food  may  still  be  found  in  the 
discharges.  As  soon  as  possible,  therefore,  the  bowel  should  be  cleared 
by  the  administration  of  a  dram  of  castor  oil.  If  this  be  rejected,  calomel 
should  then  be  given  in  divided  doses,  i  gr.  being  rubbed  up  with  sugar 
and  divided  into  10  doses,  and  put  on  the  tongue  every  five  to  ten  min- 
utes until  the  stools  assume  the  characteristic  green  color.  The  ad- 
ministration of  milk  should  be  wholly  suspended,  and  nothing  but 
teaspoonful  doses  of  water  that  has  been  boiled  should  be  given  every 
few  minutes  for  more  than  an  hour  at  a  time. 

In  an  attack  of  cholera  morbus  in  adults  the  first  thing  to  do  is  to 
irrigate  the  bowel  as  we  would  in  children,  and  also  to  use  the  hypo- 
dermic of  camphor  in  oil  in  a  dose  of  7  gr.  of  camphor  at  a  time;  also, 
if  the  stomach  remains  irritable,  it  should  be  washed  out.  Should 
the  diarrhea  persist,  20  gr.  of  subcarbonate  of  bismuth  may  be  ad- 
ministered every  hour  or  two,  and  in  adults  there  is  no  objection  to 
the  administration  of  from  i  to  |  gr.  of  morphin.  As  above  remarked, 
the  state  of  the  kidneys  should  be  carefully  watched. 


APPENDICITIS  377 

APPENDICITIS 

As  if  we  did  not  have  enough  ways  for  djdng,  the  useless  organ  of 
the  appendix  vermiformis  seems  provided  to  act  as  a  trap  to  ensure 
our  removal.  In  construction  it  consists  of  a  small  narrow  tube  lined 
by  mucosa  which  is  very  prone  to  catarrhal  inflammation,  caused  by 
the  entrance  into  it  of  fecal  masses  or  foreign  bodies  from  the  cecum, 
to  which  the  appendix  is  attached,  and  which  cannot  be  easily  got  rid 
of  simply  because  at  its  lower  end  it  is  a  closed  tube.  On  that  ac- 
count the  Mayo  brothers,  as  a  result  of  their  extensive  experience,  say 
that  a  healthy  appendix  is  rare. 

Appendicitis,  therefore,  is  a  common  affection  responsible  for  a 
large  number  of  deaths  in  all  countries,  but  especially,  according  to 
statistics,  in  the  United  States.  The  reasons  for  some  of  its  proved 
antecedents  are  obscure,  one  of  them  being  the  existence  of  a  rheumatic 
constitution,  for  more  than  one  case  is  reported  of  an  appendicitis 
following  closely  upon  an  inflammation  of  the  tonsils,  which  is  such  a 
common  antecedent  of  rheumatic  fever.  In  the  majority  of  cases,  how- 
ever, no  definite  antecedents  can  be  mentioned,  appendicitis  occur- 
ring in  such  healthy  individuals  that  no  preventive  measures  can  be 
adopted. 

Attention,  therefore,  cannot  be  too  assiduously  paid  to  the  first 
symptoms  of  this  complaint,  of  which  localized  pain  is  of  leading 
importance.  The  onset  of  this  pain  is  commonly  sudden,  and  usually, 
but  not  always,  definitely  locaHzed  in  the  right  iHac  fossa.  It  soon 
develops  aU  the  characters  of  an  inflammatory  pain,  being  aggravated 
by  pressure  over  its  seat,  which  itself  may  be  diagnostic.  It  has  been 
called  McBurney's  point,  localized  at  the  intersection  of  a  line  drawn 
from  the  navel  to  the  anterior  superior  spine  of  the  ilium,  with  a  second, 
vertically  placed,  corresponding  to  the  outer  edge  of  the  right  rectus 
muscle.  Not  uncommonly,  the  pain  of  appendicitis  is  diffused,  espe- 
cially about  the  navel,  or  even  referred  to  the  left  iliac  fossa,  but  in 
every  case  deep  pressure  with  the  index-finger  over  McBurney's  point 
will  show  that  this  is  the  true  center  of  the  inflammation.  Further 
development  of  inflammatory  signs  will  soon  follow.  The  muscular 
tissues  over  the  seat  of  the  inflammation  become  rigid  and  resistant, 
particularly  along  the  right  rectus  muscle,  not  infrequently  giving 
the  sensation  of  a  localized  tumor,  while  the  patient  Hes  preferably  on 
his  back,  with  the  right  leg  drawn  up.  If  the  inflammation  extends 
the  movements  of  the  abdominal  muscles  on  the  right  side  in  breath- 
ing are  plainly  checked.  A  valuable  sign  at  this  stage  is  irritability  of 
the  bladder,  soon  followed  by  nausea  and  vomiting. 


378  CLINICAL  MEDICINE 

The  pulse  also  affords  valuable  signs,  for  if  pus  is  forming,  it  rises 
in  frequency,  according  to  the  extension  of  the  inflammation.  Thus,  if 
the  local  pain  has  been  allayed  by  the  application  of  ice,  yet  the  pulse 
continues  to  rise  and  approximate  120  beats,  it  is  a  pretty  sure  sign 
of  abscess  formation.  The  local  application  of  ice  is  very  often  suffi- 
cient to  check  this  inflammation  then  and  there.  Whether  or  not 
an  abscess  is  forming,  it  becomes  an  anxious  question  if  the  symp- 
toms of  the  illness  continue  after  the  third  day  from  the  onset. 
When  pus  does  form,  there  is  no  telHng  in  what  directions  it  may 
burrow. 

I  had  a  young  man  once  sent  to  me  from  Cleveland,  Ohio,  on  a 
special  train  because  he  was  discharging  pus  from  an  external  opening, 
which  was  so  offensive  in  its  character  that  it  scented  the  whole  room. 
I  succeeded  in  deodorizing  this  discharge,  only  to  find  that  the  pus  bur- 
rowed its  way  along  the  spinal  column  until  the  last  opening  for  the 
evacuation  of  the  pus  was  made  at  the  nape  of  the  neck.  It  was  more 
than  a  year  before  these  purulent  collections  ceased,  but  the  case  ended 
a  year  after  that  by  extensive  amyloid  disease  of  the  fiver,  kidneys, 
and  other  organs,  ah  results  of  chronic  suppuration.  In  other  cases 
the  pus  may  likewise  avoid  the  peritoneum  altogether,  and  instead, 
burrowing  along  the  spinal  column,  perforate  the  diaphragm  and  burst 
into  the  lungs,  of  which  I  have  had  several  cases. 

An  interesting  form  of  chronic  appendicitis  is  that  in  which  the 
organ  shrivels  up  into  a  more  or  less  long  cord,  very  frequently  with 
adhesions  formed  either  to  the  intestines,  particularly  the  ascending 
colon,  or  to  various  contiguous  parts.  These  cases  may  give  rise  to 
a  great  variety  of  annoying  abdominal  S3miptoms,  whose  connection 
with  former  appendicitis  may  not  be  suspected.  One  common  cause 
is  from  kink  of  the  intestine,  which  may  result  from  the  surgical  opera- 
tion for  appendicitis. 

Treatment. — The  non-surgical  treatment  for  appendicitis  should 
be  limited  to  the  appfication  of  the  ice-bag  upon  the  first  attack, 
which  in  a  large  number  of  cases,  along  with  perfect  rest,  suffices  to  cure 
the  disease.  I  have  had  several  patients  who  have  thus  recovered 
from  their  first  attack,  and  who  have  remained  well  for  years  subse- 
quently. The  case  is  wholly  different  with  recurring  attacks.  For 
these  now  I  never  fail  to  recommend  a  surgical  operation,  because 
though  they  may  recover  after  two  or  three  recurrences,  yet  we  can 
never  be  sure  but  that  in  one  of  them  perforation  and  general  peritoni- 
tis may  not  happen.  That  great  remedy  for  inflammatory  pain,  opium, 
should  not  be  administered  in  suspected  appendicitis,  because  by  its 


MUCOUS    COLITIS  379 

relief  of  the  pain  it  may  mask  the  serious  progress  of  this  often  seem- 
ingly accidental  complaint. 

MUCOUS  COLITIS 

It  is  to  be  hoped  that  but  few  physicians  will  be  called  upon  to 
treat  a  case  of  membranous  colitis  at  the  outset  of  their  career,  for  if  so 
they  will  be  apt  to  think  that  they  have  made  a  serious  mistake  in  the 
choice  of  their  Ufe-calling.  The  sanguine  expectations  with  which 
they  left  college,  that  success  in  practice  is  sure  to  follow  good  training 
and  earnest  endeavor,  are  likely  to  be  disappointed  in  every  particular 
and  in  the  most  trying  fashion  whenever  a  patient  comes  with  a  story 
of  chronic  habit  of  passing  long  shreds  or  membranous  casts  of  the 
bowel. 

The  experienced  clinician  has  learned  to  note  early  in  eyes  and 
forehead  signs  of  head  trouble,  and  about  the  nostrils  and  the  upper 
lip  signs  of  thoracic  derangement,  but  when  the  corners  of  the  mouth 
go  down  in  woebegone  expression  he  knows  that  inward  grief  reigns 
somewhere  in  the  abdomen.  But  of  all  physiognomies,  a  case  of  mem- 
branous colitis  wears  the  most  settled  aspect  of  confirmed  wretched- 
ness, which  the  young  physician,  confident  in  his  resources,  meets 
with  assurances  of  coming  relief.  But  his  subsequent  experience  is 
apt  to  be  much  as  follows:  For  some  days  his  remedies  seem  to  be 
working  well.  Then  the  old  pains  in  the  bowels  return,  now  with  a 
sense  of  general  distress  pervading  the  abdominal  cavity,  best  de- 
scribed by  the  colored  woman's  term  "misery."  Then  follows  a  more 
locaHzed  pain,  either  griping  or  cutting  or  sickening,  which  is  explained 
as  due  to  wind  for  often  various  rumbhngs  precede  or  accompany  it. 
The  abdominal  parietes  frequently  become  very  tender  to  palpation 
in  places,  but  no  dependence  can  be  placed  upon  such  local  signs,  for, 
at  the  next  visit,  they  are  somewhere  else,  although  as  bad  as  ever. 
Meanwhile  the  patient  develops  a  decidedly  varied  train  of  nervous 
symptoms.  The  mind  refuses  to  think  or  to  do  anything  but  feel 
conscious  of  distress.  Unbearable  headaches,  neuralgias,  and  pains 
here  and  there,  palpitation,  sinking  spells,  and  weeping  make  up  the 
story,  until  finally  the  bowels,  with  exhausting  pains  empty  them- 
selves of  quantities  of  long  strings  or  strands  of  mucous  masses,  mixed 
with  the  feces  or  following  them,  sometimes  with  a  few  streaks  of  blood 
and  rarely  with  a  small  amount  of  pus.  Then  for  a  while  there  is 
comparative  quiet,  but  sooner  or  later  the  old  story  is  repeated,  with 
every  accompanying  variety  of  dyspeptic  symptoms,  referred  now  to 
the  stomach  and  now  lower  down,  and  each  time  explained  by  this  or 


380  CLINICAL  MEDICINE 

that  offence  in  diet,  by  the  late  bad  weather,  or  something  of  that 
character. 

In  no  other  complaint  is  the  morbid  self-consciousness  characteristic 
of  abdominal  affections  more  marked.  The  patient  can  neither  think 
nor  talk  about  any  other  subject  than  his  many  woes.  Therefore, 
by  reason  of  the  great  frequency  as  well  as  variety  of  the  accompany- 
ing nervous  symptoms,  many  writers  have  been  led  to  regard  the  dis- 
ease as  primarily  a  neurosis,  or,  at  least,  to  speak  of  a  nervous  colitis. 
I  regard  this  view  of  its  pathology  as  analogous  to  that  of  the  philos- 
opher who  admired  the  wisdom  of  the  Creator  in  causing  large  rivers 
to  flow  past  large  towns.  A  colon,  the  Uning  of  which  has  fallen  into 
the  condition  which  such  a  secretion  indicates,  presents  wide  tracts 
of  surface  for  the  absorption  of  all  kinds  of  excrementitious  poisons 
into  the  blood.  It  is  these  poisons  which,  circulating  everywhere 
where  there  are  nerves,  produce  all  the  symptoms  referable  both  to  the 
splanchnic  and  to  the  cerebrospinal  tracts,  which  make  up  the  multi- 
form nervous  features  of  the  case,  and  offer  a  sufficient  explanation 
of  them  without  needing  the  intervention  of  any  vague  primary  ner- 
vous lesion. 

Moreover,  while  nervous  lesions  or  irritations  do  sometimes  produce 
trophic  changes,  nevertheless  no  instance  can  be  cited  of  chronic 
fluxes  from  mucous  membranes  having  any  such  origin.  Chronic 
bronchorrhea  and  chronic  gleet  certainly  are  never  primarily  neuroses, 
although  asthmatic  spasm  may  compHcate  the  one,  or  an  irritable 
stricture  the  other.  The  truth  is,  that  while  in  membranous  colitis 
the  patient  may  be  reduced  to  a  state  of  pitiable  emotional  weakness, 
the  objection  to  the  view  that  this  indicates  a  nervous  etiology  is  that 
it  leads  us  in  a  wholly  wrong  direction  when  the  subject  of  treatment 
comes  into  consideration.  How  independent  of  any  antecedents  of  a 
neurotic  kind  this  affection  may  be  is  illustrated  by  the  following  case : 

Dr.  H.  A.,  a  middle-aged  physician  in  active  practice,  had  always 
enjoyed  excellent  health  until  he  accepted  a  staff  appointment  in  the 
volunteer  service  during  the  late  Spanish  War.  While  on  cavalry 
duty  at  a  camp  in  Virginia,  which  required  his  being  for  hours  in  the 
saddle,  in  July,  1898,  he  began  to  suffer  from  an  intense  irritation 
referred  to  the  rectum.  This  measurably  subsided  for  a  time,  but 
returned  in  November  and  steadily  grew  worse  during  the  following 
winter.  He  then  had  his  sphincter  stretched  by  a  rectal  specialist, 
but  with  no  benefit.  His  symptoms  were  recurrent  attacks  of  severe 
tenesmus  which  tormented  him,  especially  at  night,  preventing  sleep, 
and  which  were  accompanied  by  discharges  of  large  quantities  of 


MUCOUS    COLITIS  38 1 

mucus.  He  lost  40  pounds  in  weight  and  was  obliged  to  give  up 
practice.  He  came  to  me  for  treatment  in  May,  1899.  Examination 
showed  the  rectal  mucous  membrane  to  be  deeply  congested,  but  there 
were  no  signs  of  ulceration.  After  six  weeks  of  recourse  to  remedial 
measures,  which  will  be  mentioned  later,  he  was  reheved  of  his  urgent 
symptoms,  so  that  he  regained  his  weight  and  was  enabled  to  resume 
practice,  but  every  now  and  then  he  has  had  temporary  relapses  and 
has  passed  complete  casts  of  the  bowel  of  greater  or  less  length.  These 
in  turn  ceased,  but  in  January,  1900,  he  reported  another  return  of 
tenesmus  and  reappearance  of  the  membranous  casts.  He  has  again 
improved,  and  I  have  hopes  that,  Uke  many  other  cases,  his  relapses 
will  grow  fewer  and  at  last  cease  altogether.  But  what  I  would  note 
here  is,  that  although  he  began  to  develop  all  the  train  of  nervous 
symptoms  referred  to,  there  can  be  no  doubt  that  none  of  them  had  any 
primary  relationship  to  his  trouble,  but  were  purely  secondary.  The 
beginning  of  the  disease  was  clearly  due  to  a  local  irritation  excited  by 
local  causes,  acting  first  on  the  lower  end  of  the  intestinal  tract,  and 
gradually  extending  upward.  In  like  manner,  one  of  the  worst  cases 
for  nervous  complications  which  I  have  met  was  in  a  young  married 
woman  who  dated  her  disorder  from  prolonged  riding  in  the  country 
on  a  bicycle. 

Now,  what  does  pathologic  anatomy  reveal  as  to  the  nature  of 
this  disease?  Unfortunately,  it  must  be  admitted  that  autopsies 
show  us  rather  what  this  intestinal  disorder  is  not  than  what  it  is. 
Thus,  with  beginners,  it  is  very  natural  to  surmise  that  extensive  tracts 
of  ulceration  will  be  found  in  the  colon.  But  generally  nothing  of  the 
kind  is  discovered,  although  the  morbid  process  has  continued  severely 
for  months  and  years  until  the  patient  succumbs  to  it.  Instead,  the 
colon  is  found  considerably  dilated,  its  walls  thin  and  atrophied,  with 
here  and  there  patches  of  simple  congestion;  toward  the  lower  end 
clumps  of  small,  thin  veins,  not  collected  into  polypi  nor  resembling 
hemorrhoids,  are  found,  and  evidently  these  are  the  source  of  the  bright 
red  blood  which  is  often  mixed  with  the  mucous  discharges,  but  even 
they  do  not  show  that  their  coats  have  been  opened  by  an  ulcerative 
process.  Microscopic  examination  of  the  discharged  membranes 
themselves  shows  nothing  but  a  structureless  material  which  is  albu- 
minous in  composition,  but  containing  no  fibrin  even  in  the  most  con- 
sistent patches,  and  in  typical  samples  wholly  devoid  of  pus  or  leuko- 
cytes, or  of  other  ingredients  of  inflammatory  exudates,  the  cells  pres- 
ent evidently  being  the  epithelial  cells  of  the  large  intestine  which  have 
undergone  fatty  degeneration. 


382  CLINICAL  MEDICINE 

Symptoms. — The  clinical  symptoms  also  are  quite  unlike  those  of 
ulcerative  colitis,  for  obstinate  constipation,  as  a  rule,  both  precedes 
and  accompanies  membranous  colitis,  while  diaridiea  as  uniformly  ac- 
companies ulcerative  coHtis. 

There  are  several  forms  of  secondary  membranous  coHtis,  on  the 
other  hand,  which  have  nothing  in  common,  excepting  the  formation  of 
membranous  patches,  with  the  disease  which  we  are  consideri'ng,  either 
in  their  etiologic  or  in  their  clinical  characters.  Thus,  in  some  cases 
of  chronic  Bright's  disease,  the  patients  he  comatose  for  days  and 
pass  loose  movements  in  bed.  After  death  the  colon,  as  well  as  parts 
of  the  small  intestine,  are  found  lined  with  thick,  diphtheric-looking 
patches,  while,  because  such  .membranous  exudations  never  appeared 
in  the  dejecta,  their  existence  v\/-as  demonstrated  only  on  the  postmor- 
tem table.  On  the  other  hand,  the  presence  of  both  albuminuria  and 
of  hematuria  is  not  unconlmon  as  temporary  symptoms  in  true  mem- 
branous coUtis.  In  two  patients  of  mine  I  have  noticed  these  signs  of 
direct  irritation  of  the  kidney  repeatedly,  but  I  do  not  place  much  store 
upon  them,  for  other  signs  of  progressive  renal  disease  have  remained 
absent,  although  these  patients  have  been  under  my  continuous  ob- 
servation for  several  years.  I  ascribe  these  renal  symptoms  to  the 
entrance  of  the  Bacillus  coH  into  the  blood  through  the  diseased  intes- 
tinal wall. 

A  case  of  true  membranous  colitis,  such  as  we  have  been  consider- 
ing, has  no  real  resemblance  to  a  catarrhal  colitis  or  to  a  catarrhal 
inflammation  of  any  kind.  What  leads  to  a  confusion  between  this 
particular  affection  and  others,  the  seat  of  which  is  in  the  large  intestine, 
is  the  presence,  more  or  less  common  to  them  all,  of  colonic  symptoms. 
Just  as  any  form  of  arthritis,  whether  traumatic,  rheumatic,  gouty, 
gonorrheal,  pyemic,  etc.,  will  cause  very  similar  symptoms  of  pain 
on  movement  of  the  joints,  with  redness,  swelling,  etc.,  so  that  the  most 
diverse  varieties  of  arthritis  can  be  confounded  in  diagnosis  and  even 
in  nomenclature — witness  that  impossible  hybrid,  rheumatic  gout — 
so  every  serious  process  in  the  colon,  will  occasion  abdominal  distress, 
tenesmus,  or  ''bearing  down,"  or  pain  before  and  during  defecation,  etc. 
It  is  only,  therefore,  when  we  have  set  these  colonic  symptoms  aside 
and  direct  our  attention  to  the  conditions  which  they  present,  as  sep- 
arately characteristic  of  each  form,  that  it  becomes  plain  that  in 
true  membranous  coUtis  we  have  a  specific  affection  of  the  large  in- 
testine, the  pathology  of  which  is  undoubtedly  distinct  from  all  other 
colonic  disorders,  with,  in  all  probabiHty,  as  specific  an  etiology. 

From  the  chnical  side  some  of  the  etiologic  factors  appear  to  be  due 


MUCOUS    COLITIS  383 

to  direct  mechanical  irritation  of  the  rectum,  as  from  horseback  or  bicy- 
cle riding,  as  already  mentioned  in  two  of  my  cases.  Similar  to  these  are 
cases  traceable  to  pressure  on  the  rectum  by  uterine  fibroids,  and  it  is 
well  to  examine  carefully  in  women  for  the  presence  of  such  possible 
causes.  In  my  opinion,  however,  by  far  the  commonest  cause  is  the 
prolonged  retention  of  hardened  scybala.  A  history  of  preceding 
habitual  constipation  of  years'  standing  is  the  rule  in  these  patients, 
and,  hence,  the  greater  frequency  of  the  complaint  in  women.  It  is 
striking  to  find,  when  we  carefully  investigate  the  antecedents  of  most 
of  these  female  patients,  how  evidently  they  have  been  subject  to 
fecal  retention  for  months  at  a  time,  and  there  is  nothing  which  favors 
the  formation  of  stationary  hard  lumps  of  feces  in  the  weakened  and 
distensible  colon  as  the  habitual  use  of  certain  laxatives  and  cathar- 
tics. One  of  the  largest  masses  of  the  kind  which  I  have  ever  had  to 
deal  with  proved  on  examination  to  consist  mainly  of  fig-seeds.  Once 
this  irritation  awakens  the  morbid  process  in  the  colon,  it  seems  to 
change  the  nutrition  of  the  intestinal  wall  in  its  own  special  way,  with 
a  definite  tendency  for  this  initial  local  change  to  spread  in  the  wall 
either  upward  or  downward,  according  to  its  first  seat,  and,  finally,  to 
induce  a  permanent  perverted  secretion,  which  becomes  very  difficult 
to  alter  or  to  cure. 

Treatment. — As  to  treatment,  the  first  indications  are  to  relieve 
the  colonic  symptoms  proper,  as  they  may  be  termed,  that  is,  symptoms 
which  are  more  or  less  common  to  all  diseases  of  the  colon,  as  pain  and 
stiffness  of  the  joints  on  movement  are  common  to  all  varieties  of  ar- 
thritis. Thus,  nothing  is  so  soothing  to  the  tenesmus,  the  cutting  and 
bearing-down  pains,  and  the  general  abdominal  distress,  asiree  irriga- 
tion of  the  colon  with  normal  sahne  solution,  to  which  may  be  added 
oil  of  peppermint,  5  drops  to  the  pint.  Three  to  5  gallons,  at  a  tem- 
perature of  100°  F.,  may  be  employed  once  in  twelve  hours,  and  given 
by  Kemp's  rectal  irrigator,  according  to  the  printed  directions  which 
are  furnished  with  this  simple  and  serviceable  instrument.  The  rehef 
which  this  hot  douche  affords  is  often  described  by  the  patients  as 
very  great,  and  as  enabling  them  to  sleep  at  night  better  than  any 
other  measure.  Care  must  be  taken,  however,  that  all  the  fluid  is 
returned,  lest  any  quantity  retained  may  afterward  provoke  a  return 
of  pain,  thus  causing  it  to  act  as  an  enema.  By  a  little  practice,  how- 
ever, this  may  be  avoided.  Great  quantities  of  jnucus  are  thus  dis- 
lodged and  washed  away,  but  it  frequently  happens  that  after  the  irri- 
gation has  been  employed  the  patient  subsequently  has  a  painless 
movement  which  consists  of  a  large  amount  of  simple  mucus  without 


384  CLINICAL  MEDICINE 

shreds  or  membrane.  Sometimes  I  have  found  benefit  from  using  at 
the  end  of  the  irrigation  a  gallon  of  the  water  in  which  from  60  to  100 
gr.  of  resorcin  have  been  dissolved,  being  careful  that  it  is  all  expelled 
afterward.  Once  a  week  a  pint  of  clean,  hot  water,  with  30  to  40  gr. 
of  silver  nitrate,  may  be  used  instead  of  the  resorcin.  Unfortunately, 
this  irrigation  is  not  curative,  as  it  is  in  many  cases  of  chronic  catarrhal 
or  chronic  ulcerative  colitis,  for,  although  it  serves  the  valuable  ser- 
vice of  ehminating  the  complication  of  direct  colonic  irritation  which  so 
often  undermines  the  patient's  health,  and,  by  so  much,  aggravates 
the  local  processes  of  the  disease,  yet  it  does  not  deal  with  the  nutritive 
change  itself  in  the  intestinal  wall,  but  only  some  of  its  effects.  Never- 
theless, it  should  not  be  omitted  from  the  system  of  measures  which 
should  be  adopted  for  the  more  or  less  prolonged  methods  of  treatment 
needful  in  every  essentially  chronic  disease. 

The  question  arises.  Have  we  any  medicinal  remedies  which  can  be 
expected  to  be  of  service  in  changing  the  disordered  nutrition  of  the 
intestinal  mucous  membrane?  I  believe  that  we  have  one  such  remedy, 
and  that  is,  small,  and  what  I  may  call  alterative,  doses  of  castor  oil. 
I  have  had  patients  report  that  the  rehef  afforded  by  this  medicine  has 
been  most  unmistakable  from  its  first  administration.  I  prescribe  it 
in  an  emulsion,  of  which  each  tablespoonful  contains  from  |  to  i  dram 
of  the  oil,  preferably  ^  dram  at  first,  to  be  taken  either  half  an  hour 
before  meals  or  an  hour  after  meals.  This  should  be  continued  for 
months  together,  and  only  intermitted  when  it  seems  unmistakably 
to  increase  the  patient's  dyspeptic  symptoms. 

The  nitrate  of  silver  in  J-gr.  doses,  combined  in  pill  or  capsule  form 
with  9  gr.  of  turpentine  resin,  and  taken  three  times  a  day,  is  some- 
times of  much  service,  although  not  as  uniformly  as  in  chronic  catarrhal 
or  ulcerative  colitis,  in  which  complaints  J  gr.  of  opium  is  added. 
To  enable  the  turpentine  to  dissolve  and  not  pass  the  bowels  unchanged 
it  should  be  pulverized  well  with  licorice  powder  and  a  drop  or  so  of 
liquor  potassae  added  to  each  capsule.  After  the  silver  has  been  taken 
for  six  weeks,  the  sulphate  of  copper  in  |-gr.  doses  can  be  substituted 
for  it. 

Meantime,  membranous  colitis  is  a  complaint  particularly  charac- 
terized by  general  disturbance  of  the  digestive  functions  of  the  whole 
alimentary  tract.  This  is  a  result,  and  not,  as  many  deem  it,  a  cause 
of  the  colitis ;  but  there  can  be  no  doubt  that  the  consequent  maldiges- 
tion and  fermentation  of  the  ingesta  become  of  themselves  a  complica- 
tion of  the  original  complaint.  The  stomach  is  apt  to  be  dilated  and 
the  small  intestine  the  seat  of  disturbed  innervation  and  a  perverted 


MUCOUS   COLITIS  385 

secretion.  Five  grains  of  resorcin  in  solution  with  tincture  nucis  vom- 
icae, half  an  hour  after  meals,  constitutes  a  good  prescription  for  the 
gastric  symptoms,  to  be  supplemented  by  lo  gr.  of  sodium  benzoate 
and  10  gr.  of  bismuth  salicylate  in  capsules,  an  hour  after  each  meal,  as 
intestinal  antiseptics.  We  should,  however,  from  the  first  bear  in 
mind  the  probable  dependence  of  the  disease  itself  on  chronic  consti- 
pation, and  against  this  I  would  limit  myself  to  the  employment  of 
salines  exclusively.  From  i  to  2  drams  of  phosphate  of  soda  with  10 
gr.  of  saKcylate  of  soda  should  be  given  every  morning  in  a  tumblerful 
of  water  as  hot  as  the  patient  can  sip  it.  After  a  time  the  same  quan- 
tities of  sulphate  of  magnesium  may  be  substituted.  Daily  massage 
of  the  bowels,  particularly  of  the  tract  of  the  colon,  is  also  to  be  highly 
recommended.  We  need  not  fear  arousing  any  inflammatory  process 
by  such  manipulation,  for  we  are  not  dealing  with  inflammatory  dis- 
ease. Once  in  a  while,  however,  we  do  find  a  region  which  always 
remains  tender  to  palpation,  and  in  such  cases  a  local  blister  often  is 
beneficial. 

The  diet  of  such  patients  is  important  to  consider,  if  only  from  the 
fact  that  many  of  them  most  unwarrantably  reduce  it  from  fear  of 
this  or  that  article  disagreeing  with  them,  according  to  their  remem- 
brance of  some  severe  attack  after  they  partook  of  it,  until  they  finally 
live  on  only  some  very  few  and  insufiicient  forms  of  food.  We  may 
simply  exclude  beans,  corn,  spinach,  and  the  woody  vegetables,  along 
wdth  oatmeal  among  the  cereals,  and  then  encourage  the  patients  to 
eat  meat,  poultry,  eggs,  zoolak  or  koumiss,  peptonized  milk,  and 
most  cereals,  with  instructions  not  to  care  what  will  happen.  In  some 
cases  pancreatic  emulsion  is  of  marked  service. 

Finally,  bodily  movement  and  out-of-door  exercise  is  beneficial  on 
general  principles.  Repeatedly  we  find  a  summer  change  to  the 
country  does  more  good  than  anything  else,  for  fresh  air  is  the  best 
remedy  for  constipation  that  can  be  named,  and  its  effect  is  not  lost  in 
disease. 

Recent  writers,  notably  Hale  White,  have  recommended,  whenever 
everything  else  fails,  to  give  the  colon  a  prolonged  rest  by  the  estabhsh- 
ment  of  an  artificial  anus  in  the  right  flank.  Some  recoveries  have 
been  reported  from  this  procedure,  and  I  see  no  reason  why,  in  other- 
wise hopeless  cases,  it  should  not  be  tried. 

Dr.  R.  F.  Weir,  of  New  York,  has  suggested  a  mode  of  treatment 
which  is  often  curative,  and  that  is  to  cut  down  upon  the  appendix 
vermiformis  and  attach  it  to  the  abdominal  wall.  Then  he  opens 
the  tip  of  the  appendix  and  proceeds  to  wash  out  the  colon  through 

25 


386  CLINICAL   MEDICINE 

this  artificial  opening,  using  simple  saline,  to  which  I  would  add 
peppermint  as  the  agent  for  this  kind  of  lavage.  By  thus  daily  cleans- 
ing the  whole  colonic  tube  he  has  succeeded  in  arresting  the  com- 
plaint altogether. 

BACILLARY  DYSENTERY 

It  is  as  incorrect  to  term  dysentery  a  coUtis  as  to  call  an  eruption 
of  small-pox  a  dermatitis,  because  the  chief  forms  of  dysentery  are  due 
to  an  actual  infection  by  two  wholly  distinct  agents,  the  first  a  bacillus, 
and  the  second  a  different  agent  because  it  is  of  animal  origin,  namely, 
the  Amoeba  dysenterica. 

Although  dysentery  has  been  known  from  ancient  times,  it  was  not 
until  the  latter  part  of  the  19th  century  that  its  being  due  to  specific 
infections  was  demonstrated. 

Dysentery  is  one  of  the  oldest  of  known  affections,  as  it  is  described 
by  Hippocrates  and  in  Eber's  Egyptian  Papyrus  1750  years  before 
him.  In  all  ages  it  has  been  the  scourge  of  armies,  while  it  also 
occurs  as  a  local  epidemic  in  jails  and  prisons.  It  always  has  pres- 
ent the  same  characteristic  of  attacking  the  lower  bowel,  but  it  was 
not  until  lately  that  it  was  divided  into  bacillary  and  amebic  dysen- 
tery. The  discovery  of  the  Bacillus  dysenterica  we  owe  to  the  Japanese 
bacteriologist  Shiga  in  1898,  who  showed  that  this  bacillus  prevails 
all  over  the  world.  It  is  a  short  plump  rod,  non-motile,  and  bears 
some  resemblance  to  the  Bacillus  coli.  Different  strains  of  it,  how- 
ever, have  been  demonstrated  by  their  different  reactions  on  cul- 
ture-media or  by  their  different  effects  upon  various  sugars. 

There  is  no  doubt  that  this  bacillus,  besides  being  the  specific 
cause  of  this  form  of  dysentery,  is  communicated  from  one  person  to 
another  equally  like  Asiatic  cholera  by  drinking  water  or  by  food  taken 
to  the  mouth  when  contaminated  by  the  presence  of  the  bacilli.  It 
can  infect  a  stream  of  water  and  thus  spread  the  disease  from  one  town 
to  another.  It  has  even  the  other  characters  of  such  diseases,  that 
it  may  be  disseminated  by  persons  who  are  actually  not  sick  with  it; 
in  other  words,  by  true  dysentery  carriers.  This  has  been  demon- 
strated in  the  case  of  infants  who  are  not  themselves  sick  with  the  com- 
plaint, but  whose  stools  show  the  presence  of  the  bacillus.  There  is 
no  doubt  that  the  stools  of  dysentery  patients  are  at  all  times  dangerous, 
such  as  when  the  napkins  are  soiled  by  the  discharges,  or  it  may  be 
disseminated  by  dust  and  not  at  all  unlikely  by  flies.  This  explains 
both  widespread  infections  in  camps,  and  also  local  prevalence  in 
prisons  or  other  institutions  where  individuals  are  crowded  together. 


BACILLARY    DYSENTERY  387 

Symptoms. — In  severe  cases  the  onset  may  be  sudden  and  the 
course  rapid,  so  that  death  occurs  in  about  forty-eight  hours.  Pain  is 
first  felt  in  the  bowels,  leading  to  straining  and  tenesmus,  with  frequent 
passages  of  blood,  mucus,  and  in  prolonged  cases  an  admixture  of  pus. 
The  tenesmus  becomes  very  distressing,  often  leading  to  ineffectual 
attempts  at  defecation  and,  in  children,  to  prolapse  of  the  anus.  The 
stomach  is  not  so  often  affected  as  in  diarrhea,  but  fever  sets  in 
early,  with  a  temperature  of  from  102°  to  105°  F.  and  with  a  small, 
quickened  pulse.  The  tongue  at  first  is  coated  white,  but  afterward  is 
shrunken,  red,  and  pointed.  In  chronic  cases,  which  may  last  from 
three  to  six  weeks,  the  passages  may  not  be  so  frequent,  but  they  al- 
ways have  the  same  dysenteric  character,  with  the  presence  of  mucus, 
blood,  and  often  pus.  This  latter  ingredient  is  a  pretty  sure  sign  of 
ulceration  having  already  set  in  somewhere  in  the  rectum.  There  is 
always  a  special  tendency  to  excessive  peristalsis  of  the  whole  intes- 
tinal tract.  Death  occurs  from  pure  exhaustion,  accompanied  in 
chronic  cases  by  much  emaciation. 

When  death  has  happened  in  acute  cases  we  find  the  whole  mucosa 
of  the  large  bowel  swollen  and  covered  with  an  exudation  which  may 
be  brushed  off  the  surface  of  the  membrane,  but  even  then  distinct 
patches  of  necrosis  may  be  evident,  which,  if  the  case  is  at  all  prolonged, 
become  the  sites  of  ulcers.  These,  however,  do  not  have  the  ragged 
and  excavated  edges  which  are  characteristic  of  the  ulcers  of  amebic 
dysentery.  In  other  words,  they  are  not  apt  to  involve  the  muscular 
or  serous  coats.  It  should  be  stated  that  there  are  cases  in  which 
the  upper  part  of  the  colon  is  involved,  with  extension  through  the 
cecum  to  the  ileum.  These  patients  do  not  show  the  same  tenesmus 
or  discharge  of  mucus  and  blood  characteristic  of  the  infection  when 
it  involves  the  rectum.  On  the  other  hand,  plain  toxic  symptoms  from 
a  general  absorption  of  poisonous  materials  into  the  circulation  are 
unmistakably  present. 

Treatment. — The  first  indication  for  treatment  is  to  enjoin  absolute 
rest  in  bed  until  the  symptoms  of  the  disease  have  disappeared.  It  is 
hardly  to  be  expected  that  any  person  will  get  well  if  he  continues  to 
walk,  as  is  shown  by  many  cases  leaving  their  beds  after  a  decline,  but 
not  actual  cessation,  of  the  discharges. 

As  in  other  severe  and  acute  diseases,  no  one  form  of  treatment 
should  be  expected  to  be  uniformly  successful.  My  own  experience 
for  a  number  of  years  leads  me  to  prefer  for  the  dysentery  of  our 
country  the  plan  by  which  the  bowel  is  first  evacuated  with  an  ounce 
of  castor  oil.     This  will  operate  usually  in  three  hours,  and  when  it 


388  CLINICAL   MEDICINE 

has  cleared  the  bowels  an  enema  of  20  drops  of  laudanum  in  3  oz.  of 
plain  water,  with  the  addition  of  20  gr.  of  potassium  bromid,  should  be 
given.  The  bromid  is  given  for  the  purpose  of  allaying  at  once  the 
tendency  to  reflex  peristalsis.  After  this  an  emulsion  of  i  oz.  of  castor 
oil  in  6  oz.  of  mucilage  of  gum  arable  should  be  made,  with  |  to  i  dram 
of  laudanum.  The  dose  of  this  emulsion  should  be  a  tablespoonful 
every  two  or  three  hours.  This  treatment  I  have  found  very  efficacious 
both  in  acute  and  chronic  dysentery.  In  one  case  of  discharge  of 
blood  for  two  years  it  promptly  reheved  the  patient. 

Another  method  of  treatment  particularly  recommended  by  French 
physicians  is  the  employment  of  saline  purgatives,  notably  the  sulphate 
of  soda.  It  is  first  given  in  doses  of  |  to  i  oz.  of  the  salt  dissolved  in 
water  in  the  morning,  which  will  act  usually  in  about  three  hours. 
After  this  it  is  to  be  given  in  |-oz.  doses  four  times  daily.  Major 
Buchanan  recommends  i  dram  of  sodium  sulphate  in  i  oz.  of  fennel 
or  peppermint-water  four,  six,  or  eight  times  a  day,  until  every  trace 
of  blood  and  mucus  has  disappeared.  This  treatment  is  adapted  for 
acute  cases  only. 

AMEBIC  DYSENTERY 

Wholly  distinct  in  nature  and  cause  from  bacillary  dysentery  is 
that  caused  by  amebse  or  animal  parasites.  This  is  particularly  the 
case  in  tropical  dysentery,  but,  though  uncommon  in  Great  Britain,  it 
is  very  frequent  in  the  United  States,  if  not  actually  endemic  in  the 
Southern  States  of  the  Union.  Osier  states  that  in  1908,  123  out  of 
182  cases  of  amebic  dysentery  came  from  the  vicinity  of  Baltimore. 

It  is  not  uncommon  in  children,  but  the  greatest  number  of  cases 
occurs  between  the  ages  of  twenty  and  thirty-five,  much  the  larger 
portion  being  males.  In  the  United  States  the  whites  are  much  more 
susceptible  than  the  blacks. 

This  ameba  was  first  identified  by  Lanblain  (1859),  and  subse- 
quently by  numerous  other  investigators.  It  is  from  15  to  20  mm.  in 
diameter,  has  a  clear  outer  zone  (ectosarc) ,  and  contains  a  nucleus  and 
one  or  two  vacuoles.  They  may  be  found  in  the  discharges,  and  also 
by  removal  from  the  intestinal  wall  by  a  catheter,  in  enormous  numbers. 
These  amebae  are  very  resistant  to  everything  except  contact  with 
ipecacuanha.  They  can  withstand  drying  from  eleven  to  fifteen 
months. 

The  amebae  begin  their  work  by  passing  through  the  submucosa, 
and  here  they  accumulate  at  first  in  discrete  masses,  but  then  bur- 
row under  the  mucosa  before  they  cause  its  necrosis.      This  makes 


AMEBIC   DYSENTERY  389 

the  ulcer  different  from  the  more  superficial  one  of  bacillary  dysentery, 
the  amebic  ulcer  presenting  ragged  edges  with  excavation  underneath 
the  sites,  in  some  cases  forming  along  sinuous  passages. 

Amebic  dysentery  may  present  a  mild  aspect,  the  patient  scarcely 
knowing  that  he  has  any  bowel  trouble.  On  the  other  hand,  most 
cases  present  acute  symptoms  from  the  beginning,  with  pain,  tenesmus, 
and  frequent  bloody  discharges.  A  patient's  strength  and  nutrition 
rapidly  fail,  the  heart  becomes  feeble,  and  death  may  occur  in  less  than 
a  week. 

In  former  years  I  greatly  dreaded  amebic  dysentery,  because  it 
seemed  certain  to  become  chronic  and  incurable. 

In  addition  to  invading  the  intestine,  it  has  a  special  tendency  to 
produce  abscesses  in  the  liver,  which  may  be  single  or  multiple.  Less 
commonly  they  are  on  the  lower  or  concave  side  of  the  Hver,  and,  as 
usual  with  actively  forming  pus,  they  may  work  out  their  tracks  in  all 
directions,  breaking  into  the  ascending  cava,  the  peritoneum,  or  even 
the  pericardium,  as  well  as  into  the  intestine,  occasionally  discharging 
on  the  outer  surface  of  the  body.  Single  abscesses  may  be  of  con- 
siderable size  and  are  usually  in  the  right  lobe  of  the  Hver.  Most 
commonly  they  are  on  its  convex  surface,  which  explains  their  tendency 
to  break  into  the  lungs.  The  amebae  may  be  found  in  great  numbers 
in  the  fluid,  but  more  particularly  in  the  walls  of  the  abscess.  The 
multiple  abscesses  are  usually  small  and  superficial,  but  may  be 
extremely  numerous  and  scattered  throughout  the  organ.  On  exami- 
nation they  all  contain  the  amebae. 

This  metastatic  abscess  formation,  so  to  speak,  in  the  liver  does 
not  occur  in  bacillary  dysentery.  Considering  that  many  cases  of 
amebic  abscess  of  the  liver  are  quite  latent  in  their  course,  a  physician 
should  be  on  the  watch  for  certain  symptoms.  The  first  of  these  is 
enlargement  of  the  liver,  whether  upward  or  downward,  and  not  un- 
commonly this  organ  becomes  tender  to  palpation.  But  one  of  the 
most  trustworthy  signs  is  increased  leukocytosis,  which  may  be  as  high 
as  50,000,  the  average  being  18,000;  but  where  abscess  is  not  present 
the  average  would  be  10,600.  In  rapidly  forming  abscesses  there  may 
be  chills,  fever,  and  sweating.  When  the  abscess  has  burst  into  the 
lung,  a  reddish  expectoration  occurs  in  which  amebae  are  found.  The 
ulceration  of  the  intestine  may  affect  the  whole  or  some  parts  only  of 
the  colon,  but  is  found  particularly  about  the  cecum,  the  hepatic  and 
the  sigmoid  flexures,  and  the  rectum. 

Different  from  the  bacillary  dysentery,  there  is  a  serious  tendency 
in  the  amebic  form  to  perforation  of  the  bowel.     Of  100  autopsies 


390  CLINICAL   MEDICINE 

in  Manila,  perforation  of  the  colon  took  place  in  19.  The  sloughing 
of  the  mucosa  may  in  some  cases  be  en  masse,  so  that  the  consequent 
heahng  may  cause  actual  stricture  of  the  bowel. 

Amebic  infection  may  be  present  for  weeks  without  the  patient 
knowing  it,  the  first  sign  of  its  existence  being  the  formation  of  Hver 
abscess.  It  is  a  curious  fact  that  aside  from  the  hepatic  abscesses  the 
ulceration  in  the  intestine  is  not  often  accompanied  by  formation  of 
pus.  There  is  also  a  remarkable  variety  in  the  symptoms  of  the 
complaint,  which  may  be  so  mild  as  to  consist  only  of  slight  abdominal 
pain  with  occasional  diarrhea.  But  there  is  an  acute  form  in  which 
the  onset  is  sudden,  with  much  pain  and  tenesmus,  the  stools  being 
both  bloody  and  mixed  with  passages  of  mucus.  In  some,  large  sloughs 
are  passed,  the  patient  becoming  rapidly  emaciated,  with  toxic  weakness 
of  the  heart,  death  occurring  within  a  week.  If  the  symptoms  become 
chronic,  the  emaciation  which  follows  is  more  extreme  than  in  any  other 
infection.  It  is  notable,  however,  that  these  serious  changes  of  general 
nutrition  occur  chiefly  in  the  tropics.  In  the  United  States  the  patients 
rarely,  if  ever,  show  much  loss  of  flesh,  but  only  symptoms  of  alter- 
nating constipation  and  diarrhea,  which  may  go  on  for  a  year  or  more, 
showing  intervals  of  apparent  improvement,  followed  by  relapses  after 
the  shghtest  indiscretions  of  diet. 

Treatment. — We  know  that  now  we  have  an  almost  absolute  spe- 
cific against  amebic  dysentery  in  powdered  ipecacuanha.  Years  ago 
Dr.  O'Shaughnessy  piibHshed  his  statistics  on  the  treatment  of  dysen- 
tery in  India  by  large  doses  of  ipecacuanha.  At  that  time  the  dis- 
tinction between  bacillary  and  amebic  dysentery  was  unknown,  and 
I  have  Httle  doubt  that  the  dysentery  which  he  reported  was  of  the 
amebic  form.  Recent  authors  also  recommend  massive  doses  of 
ipecacuanha  in  the  treatment  of  bacillary  dysentery,  but  I  have  my 
doubts  whether  this  drug  is  as  effective  in  bacillary  as  it  certainly  is 
in  that  due  to  amebae. 

RECTAL  ULCERS 

Ulcers  in  the  rectum,  however  produced,  are  slow  to  heal.  This 
might  be  naturally  inferred  from  the  fact  that  the  parts  cannot  long 
rest,  and  besides  are  periodically  smeared  over  by  fecal  matter.  I 
think  that  I  have  expedited  the  healing  process  in  many  cases  by  order- 
ing that  the  rectum  should  be  washed  out  after  every  passage  with 
I  to  I  pint  of  water,  to  which  a  teaspoonful  of  chlorate  of  potash  and 
5  drops  of  oil  of  peppermint  have  been  added. 


HEMORRHOIDS  391 

HEMORRHOIDS 

Hemorrhoids  are,  primarily,  enlargements  of  the  hemorrhoidal 
veins.  As  these  veins  are  the  lowest  vessels  of  the  portal  system,  it 
may  be  readily  seen  that  prolonged  congestion  of  the  hver,  occurring 
especially  in  sedentary  persons  with  tendency  to  constipation,  may 
favor  their  formation.  The  only  curative  treatment  of  hemorrhoids 
is  by  a  prolonged  course  of  mineral  waters.  Thousands  of  patients 
go  every  year  to  Kissengen,  because  the  Kissengen  Springs  are  almost 
exactly  of  the  same  composition  as  the  serum  of  the  blood  minus  its 
corpuscular  and  albuminous  ingredients.  They,  therefore,  simply 
afford  an  excess  of  fluids  natural  to  the  system,  which  excess  can  be 
got  rid  of  with  the  least  possible  drain  upon  the  fluids  and  tissues  of 
the  body.  After  several  weeks'  course  of  these  waters,  taken  in  the 
morning,  the  patients  hope  that  they  will  have  an  attack  of  inflamed 
hemorrhoids,  for  that  will  be  the  last  disturbance  from  the  piles  per- 
haps for  years.  This  treatment  also  answers  the  same  purpose  with 
bleeding  piles.  When,  on  the  other  hand,  the  hemorrhoids  inflame, 
local  treatment  by  suppositories  is  the  best,  of  which  the  kind  sold 
under  the  name  of  Anusol  I  have  found  to  be  the  most  efficacious. 
In  acute  cases,  when  the  hemorrhoids  protrude  they  may  be  treated  by 
douches  of  hot  water,  ending  with  the  sudden  appHcation  of  ice-water. 


CHAPTER    VII 

DISEASES  OF  THE  LIVER 

The  liver  is  both  the  largest  and  heaviest  organ  in  the  body. 
Structurally  no  contrast  could  be  greater  than  between  liver  and  kid- 
ney substance.  The  kidney  is  made  up  of  a  great  variety  of  tubes, 
lined  with  cells  which  differ  from  one  another  in  their  function  as  well 
as  in  their  position.  The  Hver  cell  is  always  the  same  throughout  the 
whole  organ.  Therefore,  the  kidney  presents  us  with  many  as  yet 
insoluble  problems;  the  liver  is  in  no  way  behindhand  in  this  respect, 
for,  notwithstanding  the  uniformity  of  its  makeup,  it  performs  a 
variety  of  functions,  only  a  few  of  which  are  yet  understood. 

HEPATITIS 

Hepatitis,  or  inflammation  of  the  substance  of  the  liver,  is  by  no 
means  uncommon  as  a  result  of  chronic  malarial  infection,  particularly 
if  the  patients  are  alcoholic  in  their  habits.  The  symptoms  vary 
according  to  whether  the  inflammation  has  extended  to  the  surface 
of  the  organ,  in  which  case  a  cough  may  develop,  which  is  in  no  sense 
an  expectorant  cough,  but  is  hacking  instead.  This  cough  is  due  to 
irritation  of  the  branches  of  the  phrenic  nerve  widely  distributed  on 
the  under  surface  of  the  diaphragm.  Besides  a  sense  of  weight  and 
dull  aching  pain  in  the  liver  itself,  the  irritation  of  the  phrenic  nerve 
may  cause  pain  between  the  shoulder-blades  or  at  the  top  of  the  right 
shoulder,  as  we  have  mentioned  in  speaking  of  inflammation  of  the 
liver  from  gall-stones. 

The  treatment  should  be  according  to  its  cause,  and,  in  general^ 
would  be  the  same  as  in  hepatitis  following  gall-stones. 

CHRONIC  CAPSULITIS  (PERIHEPATITIS) 

There  is  a  form  of  perihepatitis  which  is  very  chronic,  and  produces 
enormous  thickening  of  the  capsule  of  the  liver  with  consequent  shrink- 
ing of  the  organ.  Postmortem,  a  shrunken  liver  tissue  is  not  found  to 
be  cirrhotic,  but  simply  compressed  by  the  capsule.  This  disease 
does  not  occasion  ascites,  and  is  so  destitute  of  s3miptoms  that  its 
presence  is  only  revealed  at  autopsies. 

392 


JAUNDICE  393 


JAUNDICE 


We  begin  with  the  easiest  recognized  derangement  of  the  liver — 
jaundice.  In  this  affection  all  the  tissues,  with  the  significant  excep- 
tion of  nervous  matter,  become  tinged  with  the  coloring-matter  of  the 
bile.  This,  however,  should  be  noted  by  daylight  and  not  by  arti- 
ficial light.  However  produced,  its  clinical  accompaniments  are 
much  the  same. 

The  earliest  manifestation  of  jaundice  is  a  tinting  of  the  conjunctiva. 
When,  however,  the  jaundice  is  prolonged,  and  the  obstruction  more 
or  less  permanent,  the  color  changes  from  lemon  yellow,  in  simple 
jaundice,  to  a  deep  olive  green  or  a  greenish  black.  In  the  chronic 
forms  intense  itching  of  the  skin  takes  place,  but  then  itching  some- 
times precedes  the  jaundice  itself.  The  jaundiced  skin  very  often 
shows  localized  eruptions,  such  as  urticaria  and  boils,  and  patches  of  a 
red  color  will  appear  from  dilatation  of  the  capillaries. 

The  secretions  become  colored  also  with  bile-pigment,  so  that  the 
sweat  tinges  the  linen.  The  saliva  and  milk,  however,  are  rarely 
stained.  When  pneumonia  coexists  with  jaundice  the  expectoration 
may  also  be  tinted.  The  urine  becomes  very  early  affected,  changing 
sometimes  into  a  deep  black  green.  In  long-standing  cases  the  kid- 
neys also  become  irritated,  and  show  some  albumin  and  bile-stained 
tube-casts.  Other  characteristics  of  obstructive  jaundice  are  that 
no  bile  passes  into  the  intestine.  The  stools,  therefore,  are  gray-drab 
or  slate-gray  color,  and  are  usually  fetid  and  pasty.  This  gray  color 
is  in  part  due  to  the  presence  of  undigested  fat,  the  bile  having  the 
property  of  digesting  the  fats.  The  pulse  also  becomes  slow,  and  may 
fall  to  40,  or  even  below  30,  a  minute.  This  occurs  generally  only  at 
the  early  stage  of  jaundice.  Along  with  the  fall  in  the  frequency  of 
the  pulse  the  breathing  is  sometimes  very  slow,  falling  to  10  or  even  to 
7  a  minute.  Jaundice  always  causes  a  tendency  to  hemorrhage,  and 
on  that  account  surgeons  are  careful  in  operating  on  jaundiced  patients, 
for  a  hemorrhage  may  be  very  difficult  to  control.  It  is  customary, 
therefore,  for  surgeons,  previous  to  operating  on  such  cases,  to  give 
free  doses  of  the  chlorid  of  calcium,  15  to  20  gr.,  though  the  lactate  of 
calcium  is  more  easily  borne.  As  we  should  expect,  purpura  fre- 
quently complicates  jaundice,  and  in  these  cases  I  have  often  had 
much  trouble  with  the  supervention  of  hematuria.  The  most  serious 
of  the  symptoms  of  protracted  jaundice  are  those  connected  with  the 
brain.  These  often  begin  with  marked  depression  of  spirits,  and  then 
may  suddenly  develop  convulsions,  to  be  followed  by  fatal  coma.     The 


394  CLINICAL  MEDICINE 

terminal  symptoms  may  closely  resemble  those  of  uremia,  but  the 
nervous  system  is  not  often  implicated  in  jaundice  until  it  has  persisted 
for  a  long  time. 

Jaundice  is  not  a  disease,  but  a  symptom,  arising,  as  we  shall 
see,  from  many  different  causes.  The  simplest  form  is  a  catarrhal 
jaundice,  beginning  with  inflammation  of  the  duodenum,  which  ex- 
tends up  the  bile-passages,  and  in  many  cases  is  conjoined  with  inflam- 
mations of  the  head  of  the  pancreas,  which  is  traversed  by  the  common 
duct  of  the  liver.  This  form  of  jaundice  occurs  without  either  pain 
or  fever,  but  nearly  always  accompanied  with  some  gastric  symptoms; 
the  patient,  indeed,  may  not  feel  much  out  of  sorts,  and  comes  for 
advice  only  on  account  of  the  discoloration  of  the  skin.  He  should 
be  warned,  however,  to  keep  to  his  room,  for  we  are  never  certain  but 
that  other  more  serious  conditions  may  develop. 

Causes. — We  may  divide  the  cases  of  jaundice,  according  to  their 
causation,  into  the  following  classes — first,  cases  of  obstructive  jaun- 
dice, of  which  jaundice  caused  by  gall-stones  impacted  in  the  com- 
mon duct  are  the  most  usual.  We  shall,  however,  treat  of  these 
cases  in  our  section  on  Cholelithiasis.  Due  to  the  very  low  pressure 
with  which  bile  is  secreted  by  the  Hver  cells,  so  that,  in  fact,  it  re- 
sembles a  simple  leakage  instead  of  a  secretion,  some  cases  of  jaun- 
dice arise  from  very  slight  obstruction,  such  as  duodenal  catarrh, 
to  which  we  have  already  alluded.  There  are  cases  of  jaundice,  how- 
ever, in  which  the  mechanism  of  obstruction  is  obscure;  such  are  the 
cases  of  icterus  neonatorum,  occurring  in  newborn  infants  and  soon 
disappearing.  Sometimes  jaundice  becomes  pronounced  from  purely 
mental  causes,  as  in  my  practice  in  the  case  of  a  gentleman  who  had 
suffered  severe  financial  losses. 

Jaundice  sometimes  supervenes  in  the  course  of  a  specific  infection 
like  pneumonia  or  typhoid  fever.  Quite  different  from  any  of  the 
causes  mentioned  is  jaundice  due  to  the  pressure  of  tumors  on  the  bile- 
duct.     This  often  occurs  where  cancer  invades  the  liver. 

That  jaundice  may  be  produced  by  blood-poison  has  long  been 
known.  One  of  the  most  marked  and  prolonged  cases  in  my  experience 
occurred  in  a  Frenchman  who  had  been  bitten  by  a  cobra.  I  have 
known  of  exactly  similar  jaundice  being  caused  by  accidental  swallow- 
ing of  a  poisonous  dose  of  colchicum.  Moreover,  epidemics  of  infec- 
tious jaundice  have  been  reported  in  various  parts  of  the  world,  includ- 
ing the  United  States.  These  attacks  of  epidemic  jaundice  go  by  the 
name  of  Weil's  disease,  as  he  first  described  them  in  1886,  the  nature 
and  origin  of  which  infection  is  quite  unknown. 


CHOLELITHIASIS,    CHOLECYSTITIS,    AND    STENOSIS  395 

Treatment. — The  treatment  of  these  cases  should  be  to  keep  the 
bowels  acted  upon  by  saline  aperients,  one  of  the  best  of  which  is  to 
take  one-half  a  tumblerful  of  Pluto  water,  with  the  same  amount  of 
hot  water,  on  rising,  and  then  a  powder,  with  15  gr.  of  sodium  saKc- 
ylate  and  10  gr.  of  the  sodium  benzoate,  an  hour  after  meals  and  at 
night.  Occasionally,  say  once  or  twice  a  week,  a  mercurial  laxative 
may  be  taken  at  night  of  3  to  5  gr.  of  calomel,  with  30  gr.  of  compound 
jalap  powder.  If  the  case  proves  obstinate  high  enemata  of  hot 
normal  saline  may  be  used  night  and  morning. 

CHOLELITHIASIS,   CHOLECYSTITIS,  AND  STENOSIS 

Gall-stones  are  not  stones  at  all,  for  they  float  in  water  and  are 
composed  chiefly  of  albuminous  materials.  It  is  a  curious  illustration 
how  names  fetter  mental  conceptions  that  many  persons,  including 
most  surgeons,  conceive  of  these  things  as  minerals,  and  unfortunately 
too  often  act  accordingly.  The  great  difference  of  gall-stones  from 
resembling  anything  mineral  is  brought  out  when  we  learn  how  they 
are  formed,  for  we  then  find  that  there  is  no  resemblance  between  a 
urinary  calculus,  which  is  unmistakably  a  stone,  and  these  cheese-like 
substances,  which  are  misnamed  gall-stones.  So  in  their  clinical 
accompaniments  the  contrasts  are  no  less  striking.  According  to 
Kehr,  gall-stones  occasion  no  symptoms  in  95  per  cent,  of  all  cases  in 
which  they  occur.  In  one  of  my  patients  there  were  76  gall-stones  in  a 
single  bladder,  which  had  lain  there  for  no  one  knows  how  long,  until 
their  presence  was  discovered  at  operation,  but  if,  instead  of  76,  only 
one  calculus  is  present  in  the  urinary  bladder  the  patient  can  scarcely 
pass  an  hour  without  feeling  it. 

Etiology. — As  to  the  etiology  of  gall-stones,  we  have  learned  much 
of  late  years  from  researches  of  Prof.  Naunyn.  First,  in  contrast  with 
urinary  calcuH,  general  constitutional  conditions  have  little  to  do  with 
the  tendency  to  their  formation.  Nothing  like  a  uric-acid  diathesis 
or  derangements  like  those  which  cause  oxaluria  or  phosphatic  deposits 
precede  the  formation  of  gall-stones.  Instead,  they  arise  wholly  from 
local  causes  and  changes  in  the  biliary  passages  themselves  affecting 
the  bile  after  it  is  secreted. 

The  bile  itself  is  a  secretion  about  equal  in  daily  amount  to  the 
urine;  that  is,  from  2  to  3  pints,  but  of  such  low  specific  gravity  that  it 
contains  only  from  i  to  2  per  cent,  of  sohds.  It  is  secreted  by  the  liver 
cells  under  such  low  pressure  that  it  almost  resembles  a  simple  leakage, 
so  that  the  shght  obstruction  caused  by  catarrhal  swelling  of  the  mu- 
cous membrane  of  the  biliary  passages  may  suffice  to  cause  jaundice. 


396  CLINICAL  MEDICINE 

During  active  digestion  it  flows  uninterruptedly  along  the  hepatic 
bile-ducts  directly  into  the  intestines,  and  not  into  the  gall-bladder, 
this  flow  being  much  aided  by  contraction  of  the  diaphragm  in  active 
breathing.  In  the  intervals  of  digestion,  and  particularly  during  the 
repose  of  sleep,  the  biliary  outlet  is  closed  by  the  sphincter-hke  con- 
traction of  the  muscular  wall  of  the  duodenum,  and  the  bile  then  flows 
into  the  gall-bladder  instead.  In  proportion,  therefore,  to  the  slow 
digestion  and  to  the  sedentary  habits  of  many  persons  the  bile  accumu- 
lates in  the  gall-bladder  and  becomes  there  more  concentrated,  but, 
however  concentrated  it  may  be,  there  is  no  danger  of  a  formation  of  a 
gall-stone  so  long  as  the  normal  constituents  of  bile  are  held  in  solution, 
as  they  are  by  the  presence  of  bile-salts,  especially  the  glycocholate  of 
sodium.  Small  dark  precipitates  of  calcium  and  of  bilirubin,  derived 
from  the  coloring-matter  of  the  bile,  are  readily  formed,  but  would  be  of 
little  account  were  it  not  for  the  precipitation  of  layers  of  cholesterin 
about  them,  which  ultimately  form  the  major  proportion  of  gall-stones. 
Cholesterin  is  found  in  abundance  wherever  degeneration  of  cells  is 
going  on.  It  is,  therefore,  present  in  every  catarrhal  discharge  of  a 
mucous  membrane,  as  in  the  sputum  of  bronchitis  and  of  phthisis,  or 
wherever  there  is  pus.  So  soon  as  the  catarrhal  condition  of  the  gall- 
bladder sets  in  the  cholesterin  may  be  seen  in  discrete  drops  in  the 
degenerated  epithelial  cells  of  the  mucous  membrane,  which  set  it 
free  to  adhere  to  other  similar  drops,  leading  to  the  important  deduc- 
tion that  the  components  of  gall-stones  are  not  derived  from  the  liver 
itself,  but  are  generated  by  a  local  derangement  of  the  mucous  mem- 
brane of  the  biUary  passages  and  of  the  gall-bladder. 

Our  progress  in  the  pathology  of  cholelithiasis,  however,  shows  that 
gall-stones  are  direct  results  of  infection.  Everything  else  must  be 
contributory,  but  it  is  the  entrance  into  the  biliary  passages  of  micro- 
organisms which  is  the  efiicient  cause,  as  it  is  due  to  them  that  catarrh 
of  the  mucous  membranes  is  set  up.  Much  the  most  common  of  these 
bacterial  invaders,  as  we  might  expect,  is  the  Bacillus  coli  communis. 
In  some  cases  clumps  of  these  bacilli  seem  to  be  themselves  the  nuclei 
of  gall-stones,  as  Prof.  Welch  has  obtained  living  colon  bacilli  from  the 
center  of  gall-stones.  Infection  by  the  Bacillus  coli,  common  in  other 
disorders,  is  very  often  accompanied  by  chills  or  even  severe  rigors, 
and  this  explains  the  frequent  coincidence  of  chills  in  attacks  of 
biliary  colic. 

Another  bacterium  has  also  been  proved  to  initiate  cholelithiasis 
by  its  entrance  into  the  gall-bladder,  and  that  is  the  typhoid  bacillus. 
As  far  back  as  1829,  Lewis  drew  attention  to  the  frequency  with  which 


CHOLELITHIASIS,    CHOLECYSTITIS,    AND   STENOSIS  397 

the  gall-bladder  was  affected  in  typhoid  fever.  Thus,  Pratt  in  30 
autopsies  found  the  typhoid  bacillus  in  the  gall-bladder  in  2  r ,  and  Chiari 
in  19  out  of  21.  It  is  also  extraordinary  how  long  the  typhoid  bacilli 
may  remain  in  the  bladder  after  the  fever  has  ceased  and  set  up  chole- 
cystitis or  an  attack  of  gall-stones.  Thus,  Pratt  reports  a  case  in  which 
the  typhoid  bacillus  was  isolated  from  the  bile  in  the  gall-bladder  seven 
years  after  the  fever,  and  Dongern  reports  a  case  fourteen  years  after. 
Biliary  calculi  have  also  been  experimentally  produced  in  the  gall- 
bladders of  animals  by  the  injection  of  typhoid  bacilli. 

Diagnosis. — The  diagnosis  in  the  case  of  cholelithiasis  may  be 
either  easy  or  one  of  the  most  difficult  to  make  out  of  any  of  the  dis- 
orders in  the  abdomen,  which  is  saying  a  good  deal.  Moreover, 
different  from  a  stone  in  the  urinary  bladder,  it  is  not  enough  to  make 
the  diagnosis  of  a  calculus,  but  we  must  be  further  able  to  form  an 
opinion  as  to  what  else  occurs  as  the  result  of  the  local  trouble.  Ordi- 
narily, we  can  wait  till  we  see  fit  with  a  urinary  calculus  without  im- 
mediate danger  to  life,  but  with  a  bihary  calculus  we  may  soon  find 
ourselves  under  as  much  responsibility  as  in  case  of  appendicitis. 
Thus,  a  man  was  admitted  to  my  hospital  service  from  whom  it  was 
difficult  for  me  to  obtain  any  satisfactory  account  of  the  beginning  of 
his  illness,  because  he  was  dehrious  and  had  a  low  fever  simulating 
typhoid.  He  was  but  little  jaundiced,  but  an  indistinct  swelling  could 
be  made  out  in  the  region  of  the  gall-bladder.  His  blood  count  showed 
a  decided  hyperleukocytosis,  whereupon  I  had  him  transferred  to  my 
colleague.  Dr.  Brewer,  for  immediate  operation.  While  struggling  as 
he  was  going  under  the  ether  his  gall-bladder  burst  through  a  gan- 
grenous patch  in  its  wall,  but,  being  where  he  was,  he  was  speedily 
relieved  from  danger  and  made  an  uninterrupted  recovery. 

Hence,  as  in  his  case,  one  result  of  cholelithiasis  may  be  general 
septicemia  with  ulceration  of  the  gall-bladder,  permitting  the  escape 
of  the  calcuU  into  adjoining  parts,  causing  either  a  rapid,  fatal  general 
peritonitis  or  abscess  of  the  liver,  or  extensive  adhesions  of  the  gall- 
bladder to  the  Kver  and  intestines,  until  the  symptoms  due  to  these 
complications  may  wholly  obscure  the  original  ones  first  caused  by  the 
gall-stones.  With,  the  majority,  however,  there  are  histories  of  pre- 
ceding attacks  of  biliary  coUc,  as  well  as  other  prodromal  S3Amptoms, 
important  to  note  as  elements  for  early  diagnosis. 

Symptoms.— Thus,  as  regards  the  attacks,  pain  is  the  earliest  S3anp- 
tom,  and,  as  always,  pain  is  a  symptom  which  repays  study  more  than 
any  other.  In  all  typical  cases  of  gall-stones  the  pain  is  very  sudden. 
No  other  pain  is  so  sudden  in  its  onset  or  so  quickly  severe;  in  fact,  it 


398 


CLINICAL  MEDICINE 


may  kill  outright,  as  occurred  in  the  case  of  an  acquaintance  of  mine. 
This  is  not  an  inflammatory  pain,  but  is  of  the  same  nature  as  the  colic 
produced  by  a  calculus  impacted  in  the  ureter,  which  certainly  is  not 
due  to  either  inflammation  of  the  ureter  or  kidney,  because  it  has  all 
the  characters  of  stretching  pains,  which  are  different  from  those  of 
either  inflammatory  pains,  pressure  pains,  or  neuralgic  pains,  as  we 
have  already  seen  in  our  chapter  on  Pain. 

Pains  caused  by  parts  being  put  on  a  sudden  stretch,  as  by  calcuH 
while  passing  through  ducts  or  by  severe  sprains,  always  produce  im- 
mediate faintness  and  nausea,  which  other  forms  of  pain  do  not.  In 
an  inflammatory  pain  the  patient  keeps  his  hands  at  a  respectful  dis- 
tance from  the  affected  part,  whereas  in  the  case  of  a  sudden  onset  of 
hepatic  coHc  the  patient  grabs  his  side  as  forcibly  as  he  does  with 
lead-colic  or  a  limb  with  the  lightning  neuralgia  of  tabes.  The  site 
of  the  pain  is  always  most  important  to  make  out,  and  here,  as  in  all 
pains,  particular  attention  is  to  be  paid  to  the  gesture  of  the  patient. 
When  asked  to  show  where  his  pain  is  he  is  unable  to  describe  it  well, 
and,  if  severe,  he  may  say  it  is  all  over,  but,  if  asked  to  show  where 
he  first  felt  it,  his  fingers  tell  his  story  better  than  his  words. 

If  the  pain  is  due  to  a  calculus  in  the  cystic  duct  its  site  is  to  the 
right  of  the  rectus  muscle,  just  below  the  free  border  of  the  ninth  rib. 
If  the  calculus  has  passed  further  on  into  the  common  duct,  a  painful 
point  on  pressure  is  found  from  i^  to  2  inches  at  the  right  of  the  umbili- 
cus. Not  only  do  nausea  and  belching  of  wind  come  on  during  the 
pain,  but  also  vomiting,  and  sweat  breaks  out  on  the  forehead,  a  char- 
acteristic of  all  severe  stretching  pains.  Besides  its  primary  site, 
the  radiations  of  this  pain  are  characteristic,  the  patient's  hand  passes 
to  the  right,  horizontally  around  to  the  back,  and  then  up  between 
the  shoulder-blades,  and  sometimes  he  complains  of  pain  on  the  top 
of  the  right  shoulder,  but  rarely  at  the  beginning  of  his  attack.  This 
contrasts  with  the  pain  of  lead-colic,  in  which  the  patient  works  his 
hand  around  the  umbilicus,  but  does  not  pass  it  to  the  back,  or  to  the 
pain  of  renal  colic,  in  which  the  hand  goes  at  once  to  the  back  and  then 
quickly  down  the  side  and  to  the  front,  down  to  the  groin,  using  the 
border  of  the  hand  to  describe  the  downward  course  of  the  pain  and 
not  the  fingers,  as  he  does  in  hepatic  colic.  As  long  as  these  parox- 
ysmal pains  continue  to  occur  they  mean  an  impacted  calculus,  and 
the  occurrence  of  a  chill  with  them  is  another  diagnostic  sign  of  gall- 
stones as  the  cause  of  pain. 

It  is  when  a  change  occurs  in  the  character  of  the  pain  to  a  distinctly 
inflammatory  type  that  we  have  cause  for  apprehension,  and  that  is 


CHOLELITHIASIS,    CHOLECYSTITIS,    AND    STENOSIS  399 

when  local  tenderness  to  pressure  commences  and  its  area  progressively 
increases  along  with  increasing  rigidity  of  the  overlying  muscles. 

The  pains  of  gastric  ulcer  and,  still  more,  of  duodenal  ulcer  occa- 
sionally seem  like  those  in  gall-stones,  but  careful  local  examination 
will  show  tenderness  on  palpation,  with  rigidity  in  the  epigastrium 
rather  than  in  the  region  of  the  gall-bladder,  and  there  is  also  a  dis- 
tinct local  throbbing  or  pulsation  which  is  not  present  in  hepatic  colic. 
The  time  of  the  pain  commonly  differs,  for  the  gastric  pain  rarely 
comes  on  in  the  night,  as  hepatic  colic  often  does,  and  the  gastric 
pain  usually  has  some  relation  to  a  habitual  interval  after  taking 
food.  The  pain  of  gastric  ulcer  also  is  felt  more  toward  the  left  of  the 
median  line,  while  that  of  gall-stones  passes  to  the  right. 

Occasionally  displacement  of  the  right  kidney  occurs  in  women 
with  relaxed  abdominal  walls,  causing  sudden  pain,  faintness,  and 
stomach  disorders,  which  may  be  mistaken  for  an  attack  of  gall-stones, 
especially  as  a  tumor  may  then  be  felt  in  the  neighborhood  of  the 
gall-bladder.  Percussion  over  the  swelling  will  be  dull  if  the  swelling 
is  due  to  a  distended  gall-bladder,  because  that  would  be  in  front  of 
the  colon,  while  percussion  would  be  resonant  if  due  to  a  displaced 
kidney,  because  the  kidney  lies  behind  the  colon.  Moreover,  the  kid- 
ney may  be  pushed  upward  and  backward,  but  a  distended  gall-bladder 
cannot.  With  the  restoration  of  the  prolapsed  kidney  the  pain  soon 
ceases. 

On  the  other  hand,  some  cases  of  gastralgia  are  quite  diflEicult  to 
distinguish  from  biliary  colic,  and  give  rise  to  more  uncertainty  in 
diagnosis  than  any  other  pains.  They  have,  in  common  with  hepatic 
colic,  suddenness  and  severity  of  onset  and  often  vomiting  and  nausea 
as  well.  In  one  case  of  a  medical  friend  of  mine  I  diagnosed  the 
attacks  as  malaria.  They  were  extremely  severe,  but,  as  they  were  dis- 
tinctly periodic,  I  prescribed  dram  doses  of  the  fluidextract  of  ergot, 
which  promptly  reheved  him  after  quinin  had  wholly  failed.  In 
another  instance,  a  physician  consulted  me  for  severe  attacks  of  pain 
in  the  hepatic  region,  coming  on  about  5  p.  m.  and  lasting  through 
the  night,  with  great  prostration  and  vomiting,  his  pulse  dropping  down 
from  60  to  40.  These  pains  recurred  every  other  night  for  some  three 
weeks,  and  he  then  consulted  me,  whereupon  I  recommended  that  he 
have  his  blood  examined.  The  report  showed  the  presence  of  Plasmo- 
dium malarias  in  abundance.  As  before  mentioned,  I  prescribed  ergot, 
and  at  first  it  arrested  his  tertian  nocturnal  pains  completely,  but  after- 
ward they  recurred,  whereupon  I  prescribed  paregoric  with  quinin. 
(See  article  on  Treatment  of  Malaria,  Estivo-autumnal  Variety,  with 


400 


CLINICAL  MEDICINE 


Camphorated  Tincture  of  Opium.)  He  then  passed  another  interval 
of  a  week  without  any  pain,  but  at  the  end  of  that  time  he  had  a  severe 
attack  with  paroxysmal  pains  and  a  temperature  of  102°  F.,  accompa- 
nied with  white  scybalous  passages.  These  pains  I  diagnosed  as  due  to 
gall-stones,  and  put  him  on  my  treatment  for  the  same,  after  which  he 
soon  recovered.  Here  we  seem  to  have  had  both  malarial  and  gastral- 
gic  and  gall-stone  coHc  in  succession,  the  cHnical  distinction  between 
them  being  a  definite  periodic  tendency  in  the  former  and  not  in  the 
latter. 

The  gastric  crises  of  tabes  may  resemble  bihary  colic  in  the  pain 
and  the  accompanyuig  vomiting,  and,  as  sometimes  they  precede  all 
other  developments  of  tabes,  their  nature  may  not  be  suspected.  The 
persistent  vomiting,  but  especially  the  total  absence  of  tenderness  on 
pressure  in  spite  of  the  continuance  of  gastric  symptoms,  should  lead 
to  examination  for  other  signs  of  tabes  which  usually  are  readily  found. 

The  sequence  of  events  which  ends  in  a  calculus  leaving  its  resting 
place  in  the  gall-bladder  and  becoming  impacted  in  the  bile-duct,  with 
consequent  pain,  is  first  an  irritable  sensitiveness  of  the  walls  of  the 
gall-bladder,  induced  by  catarrh.  While  in  this  state  a  fresh  influx 
of  bile,  regurgitating  from  the  common  bile-duct,  distends  it  so  as  to 
produce  expulsive  contractions,  which  dislodge  a  calculus  first  into 
the  neck  of  the  gall-bladder  and  then  on  into  the  cystic  duct,  where  it 
may  stick  or  else  be  further  pushed  on  by  peristaltic  action  into  the 
common  duct.  This  may  account  for  the  greater  frequency  of  the 
first  attacks  of  bihary  coHc  occurring  at  night,  when  the  flow  of  bile  is 
the  greatest  into  the  gall-bladder,  as  above  mentioned.  When  we 
remember  that  the  cystic  duct  is  so  narrow  that  normally  only  a-  hog's 
bristle  can  pass  through  it,  this  fact  readily  accounts  for  the  agonizing 
pain  caused  by  the  stretching  of  the  duct  by  the  calculus. 

There  is  a  common  impression  that,  when  a  calculus  plugs  the  out- 
let of  the  gall-bladder  this  viscus  may  soon  become  distended  and  form 
a  tumor  which  may  be  felt,  but  the  facts  are  that  in  the  common  duct 
obstruction  the  reverse  usually  happens.  Thus,  Courvoisier  found  the 
gall-bladder  contracted  in  53  cases  of  common  bile-duct  obstruction 
and  distended  in  only  17.  We  should  remember  that  the  gall- 
bladder is  both  filled  and  emptied  Hke  a  bottle,  through  one  neck. 
That  neck  ends  in  a  short  tube,  which  is  soon  joined  by  another  tube, 
the  hepatic  duct,  which  conducts  all  the  bile  which  is  secreted.  Plug 
the  first  tube  or  the  cystic  duct  and  nothing  can  get  either  in  or  out 
that  way;  plug  the  second,  or  hepatic  duct,  and  no  bile  can  then  pass 
back  into  the  bladder,  though  the  bladder  may  stih  be  able  to  empty 


CHOLELITHIASIS,   CHOLECYSTITIS,    AND    STENOSIS  40 1 

what  has  passed  the  obstruction  in  the  common  duct.  With  the  first 
or  the  cystic  duct  closed,  the  gall-bladder  may  fill  up  and  become 
greatly  distended,  but  ordinarily  not  with  bile.  A  watery  fluid  instead 
is  secreted  from  its  walls,  much  as  if  it  were  a  closed  cyst,  and,  on  draw- 
ing this  off,  it  is  often  found  to  contain  but  little  mixture  of  biliary 
ingredients.  So  long  as  it  remains  uninfected  it  is  striking  how  little 
pain  or  disturbance  this  tumor  causes,  though  it  may  grow  to  a  great 
size  and  reach  the  pelvis  and  even  across  the  median  Une  to  the  left. 
That  it  is  a  distended  gall-bladder  may  be  inferred  by  the  important 
rule  in  abdominal  tumors,  that  they  spring  from  the  region  where  no 
free  border  can  be  felt.  In  this  case  no  free  border  can  be  felt  above, 
for  it  seems  to  be  continuous  with  the  liver,  and,  unless  bound  by  ad- 
hesions, descends  plainly  with  inspiration.  The  lower  portion  is  often 
easily  movable,  and  usually  gives  a  sensation  of  being  smooth  and 
rounded  and  of  containing  fluid.  On  the  other  hand,  a  gall-bladder 
tumor  which  is  painful  and  sensitive  to  manipulation  means  that  there 
is  cholecystitis  present,  and  all  its  other  accompaniments  must  then  be 
carefully  investigated. 

Stenosis  of  the  Bile-ducts. — Stenosis  of  the  bile-ducts  is  not  a  sepa- 
rate affection,  but  the  result  of  external  pressure  from  tumors  or  from 
chronic  inflammation  caused  by  gall-stones. 

While  nearly  every  case  of  a  fully  formed  stone  in  the  urinary 
bladder  calls  for  surgical  interference  to  get  rid  of  it,  in  my  own 
experience  only  i  out  of  43  of  those  who  suffer  from  gaU-stones  would 
ever  need  to  undergo  an  operation.  This  fact  should  be  emphasized, 
because  the  judgment  of  surgeons  on  this  subject  is  of  little  value. 
Thus,  to  cite  my  own  experience  on  this  question,  I  have  full  notes  of 
56  cases  in  which  I  was  able  to  follow  the  patients'  subsequent  history. 
It  must  be  further  stated,  that  many  of  them  were  not  only  chronic 
but  very  severe  cases.  Thus,  one  patient,  a  man,  had  violent  attacks 
covering  a  period  of  over  four  years.  Another,  a  woman,  was  repeat- 
edly jaundiced  for  five  years,  with  a  tendency  also  to  subcutaneous 
hemorrhage.  Another,  a  woman,  became  greatly  emaciated  from 
recurring  attacks,  accompanied  with  jaundice,  for  five  years,  in  one  of 
which  she  was  confined  to  bed  for  two  months  with  grave  sjrmptoms 
of  septicemia.  One  patient,  an  elderly  lady,  had  become  greatly  re- 
duced in  flesh  by  attacks  extending  over  four  years,  but  after  two 
months'  treatment,  in  1895,  she  has  remained  well  ever  since.  An- 
other patient,  a  man,  began  his  attacks  in  1890,  first  about  every  three 
months,  and  then,  as  the  intervals  were  growing  shorter,  until  they 
occurred  every  three  weeks,  accompanied  with  persistent  jaundice 

26 


402  CLINICAL  MEDICINE 

and  great  emaciation.  When  I  saw  him  in  March,  1894,  he  could 
find  no  relief  except  by  hypodermics  of  morphin.  He  soon  began  to 
improve  after  the  treatment  I  recommended,  which  he  kept  up  for 
three  months,  and  his  physician  reported,  in  January,  1902,  that  he 
had  remained  well  ever  since. 

In  none  of  these  severe  cases  was  the  relief  immediate,  so  that  it 
could  be  ascribed  to  the  passage  at  one  time  of  a  single  calculus  with 
consequent  cessation  of  symptoms.  The  gradual  and  not  sudden  re- 
covery, with  recurring  but  progressively  milder  attacks,  until  final  re- 
lief occurs,  is  a  suggestive  clinical  fact.  As  gall-stones  do  not  come 
from  the  liver,  nor  are  they  ever  composed  of  gall  or  bile,  my  own 
experience  leads  me  to  be  certain  that  the  best  solvent  is  a  free  flow  of 
Hmpid  bile  into  the  bladder  and  out  again.  We  can  readily  see,  how- 
ever, that  it  may  require  a  free  flow  for  a  number  of  weeks  to  do  so,  as 
it  would  have  first  to  check  the  catarrhal  process  in  the  walls  of  the 
biliary  passages  while  it  also  was  acting  on  the  concretions  themselves. 

Treatment. — The  first  indication  in  the  treatment  of  cholelithiasis 
is  to  prevent  bacterial  invasion  from  the  intestines.  The  commonest 
condition  which  favors  this  infection  is  the  unhealthy  state  of  the  intes- 
tinal walls,  induced  by  chronic  constipation,  for  it  is  noteworthy  how 
commonly  these  patients  admit  that  they  have  always  been  constipated 
and  have  had  to  use  laxatives  for  years  to  have  their  bowels  move  at  all. 
This  condition  also  naturally  explains  the  special  proclivity  of  women 
to  this  complaint.  For  this  purpose,  my  usual  prescription  is  phosphate 
of  soda,  2  oz.;  salicylate  of  soda,  3  drams;  and  benzoate  of  lithia,  i 
dram,  divided  into  12  powders,  i  powder  to  be  taken  in  a  tumblerful  of 
hot  water  and  sipped  slowly  on  rising  every  morning.  A  weekly  or 
biweekly  mercurial  laxative  is  also  of  the  greatest  service  for  intes- 
tinal antisepsis  and  I  never  fail  to  enjoin  it.  With  some  elderly  patients, 
however,  castor  oil  works  better  than  anything  else,  and  should  always 
be  tried  when  mercurials  seem  to  cause  more  than  a  day's  discomfort. 
As  true  cholagogues,  we  may  safely  rate  the  sodium  salicylate,  the 
sodium  benzoate,  and  the  sodium  succinate.  I  prescribe  them  con- 
stantly together,  to  be  taken  for  prolonged  periods,  in  doses  of  10  gr. 
each,  varied  occasionally,  increasing  the  dose  by  5  gr.  each  of  the  two 
latter.  Larger  doses,  especially  of  the  salicylates,  are  not  necessary. 
These  powders  may  be  taken  with  Vichy  water.  In  old  persons,  with 
hardened  and  thickened  arteries  and  weak  hearts,  4  or  5  gr.  of  sodium 
iodid  is  a  good  addition. 

Much  the  most  efficient  agent  against  gall-stones  is  olive  oil  when 
properly  administered.     The  true  mode  of  the  operation  of  oils  in 


CHOLELITHIASIS,    CHOLECYSTITIS,    AND   STENOSIS  403 

cholelithiasis  is  that  there  is  nothing  like  oils  to  produce  a  watery 
flow  from  mucous  membranes,  whether  applied  locally  or  taken  inter- 
nally. No  sialogogue  can  equal  a  teaspoon ful  of  olive  oil  held  in  the 
mouth,  on  the  principle  that  the  contact  of  oils  on  the  mouth  of  any 
secretory  duct  will  start  the  flow  from  that  duct.  Taken  internally, 
medicinal  oils  are  absorbed  into  the  blood,  and,  according  to  their 
kind,  pass  out  by  different  mucous  membranes,  excreting  an  abundant 
flow  of  watery  secretions,  derived  directly  from  the  blood  flow  of  the 
part,  so  as  to  specifically  modify  their  circulation.  We  see  this  illus- 
trated in  the  use  of  castor  oil  in  colitis,  but  so  general-  is  the  action  of 
this  oil  in  increasing  the  watery  action  of  other  tracts  also  that  I 
consider  it  a  risky  prescription  to  give  a  dose  of  castor  oil  to  an  infant 
with  bronchitis,  which  already  has  more  fluid  in  its  bronchial  tubes 
than  its  feeble  efforts  of  expectoration  can  raise.  The  action  of  olive 
oil  in  cholelithiasis  I  conceive  to  be  this:  in  the  first  place,  it  is  a  food 
oil,  and  as  such,  if  taken  in  quantity,  would  not  disturb  the  stomach; 
thus,  I  or  2  oz.  is  soon  passed  into  the  duodenum  to  excite  there,  as 
all  fats  do,  an  increased  flow  of  normal  duodenal  secretions,  namely,  the 
biliary,  the  pancreatic,  and  the  secretions  of  B runner's  glands.  No 
larger  amount  than  i  to  2  oz.  is  needed  for  this  purpose,  though  a  free 
flow  of  watery  bile  is  just  what  we  should  aim  to  secure,  with  as  little 
disturbance  of  other  functions  as  possible.  For  this  purpose  I  direct 
the  oil  to  be  taken  in  a  cup  of  hot  milk  at  night,  the  milk  greatly  assist- 
ing the  tolerance  in  the  stomach  of  such  a  quantity  of  free  oil.  To 
patients  with  cholelithiasis  this  dose  is  taken  for  ten  consecutive  nights, 
then  intermitted  for  about  a  week  to  avoid  gastric  disturbance,  and 
then  resumed  for  ten  more  nights.  The  duration  of  the  treatment 
thus  outlined  varies  according  to  the  previous  chronicity  of  the  case. 

The  gastric  derangement  accompan5dng  cholelithiasis  requires  care- 
ful management,  both  dietetically  and  medicinally.  All  fried  arti- 
cles are  injurious,  but  one  of  the  worst  for  exciting  an  attack  is 
mayonnaise  dressing  for  salads.  On  general  principles,  the  patient 
should  avoid  whatever  he  has  found  to  be  difficult  for  him  of  digestion. 
On  the  other  hand,  if  gastric  digestion  is  in  a  fair  condition,  rigid  dieting 
is  uncalled  for.  For  the  subacute  gastritis  which  commonly  accom- 
panies gall-stones,  I  have  found  very  serviceable  pills  of  2V  g^-  ^^  bi- 
chromate of  potassium  with  3  gr.  of  bismuth  carbonate,  one-half  hour 
before  meals,  and  5  gr.  of  resorcin  in  solution,  one-half  hour  after  meals. 

Indications  for  Surgical  Operation. — The  chief  dangers  which  arise 
from  gall-stones  are  only,  in  a  minority  of  cases,  due  to  the  action  of  the 
calculi  themselves.     This  occasionally  may  be  the  main  factor,  yet 


404  CLINICAL  MEDICINE 

many  of  the  worst  accidents  in  cholelithiasis  are  due  chiefly  to  a  virulent 
sepsis  causing  ulceration  and  gangrene,  with  the  most  varied  disasters 
as  the  result.  The  S3anptoms,  therefore,  of  this  condition  are  of  the 
first  importance,  whether  we  are  sure  of  the  gall-stones  being  present 
or  not,  and  we  should  carefully  weigh  the  evidence  that  gall-stones  are 
the  probable  cause.  But  often  the  existing  conditions  of  the  part 
make  a  specific  diagnosis  impossible;  therefore,  taking  the  danger- 
signals  in  the  order  of  their  importance,  I  would  put  a  continued  fever 
first.  The  readings  of  the  thermometer  are  often  very  characteristic, 
with  all  the  marked  irregularity  of  sepsis,  while  the  fever  shows  no 
resemblance  to  the  transient  rise  which  often  follows  single  paroxysms 
of  biliary  colic.  In  this  fever,  delirium,  even  if  occasional,  is  always  of 
grave  import.  Meantime  the  pulse  continues  rapid,  without  much 
reference  to  the  temperature,  and  is  generally  small.  As  they  progress 
the  constitutional  symptoms  may  be  termed  "typhoid,"  including 
dr3niess  of  the  tongue  and  occasional  sweats.  As  before  urged,  the 
blood  should  certainly  be  examined  for  a  hyperleukocytosis.  Local 
examination  should,  of  course,  be  as  complete  as  possible,  and  if  tender- 
ness and  rigidity  are  also  found  there  is  no  excuse  for  postponing 
laparotomy.  Some  may  naturally  object  that  it  is  neither  fair  to  the 
patient  nor  to  the  surgeon  to  allow  a  suspected  case  of  cholelithiasis 
to  reach  such  a  perilous  condition  before  having  recourse  to  an  opera- 
tion. The  answer  is,  that  at  the  beginning  of  such  conditions  there 
is  commonly  no  difference  from  ordinary  attacks  of  biliary  colic,  which 
are  quite  amenable  to  treatment. 

Neither  a  long  history  of  pain,  jaundice,  nor  emaciation,  etc.,  affords 
any  certainty  that  such  an  outcome  is  imminent,  while,  on  the  other 
hand,  such  grave  conditions  develop  as  often  in  patients  who  did  not 
suffer  severely  from  symptoms  of  cholelithiasis  any  more  than  do  others. 

This  has  actually  been  the  case  in  every  instance  of  the  kind  which 
I  have  met  with.  In  one  patient,  particularly,  I  made  the  diagnosis, 
although  no  history  of  gall-stone  symptoms  was  obtainable.  The 
gall-bladder  may  be  found  full  of  both  pus  and  gall-stones,  and  yet, 
without  any  story  of  attacks  of  biliary  colic  and  fatal  infective  chole- 
lithiasis, has  been  frequently  reported  without  gall-stones  being  found 
anywhere  at  autopsy.  I  repeat,  that  it  is  mainly  from  infective  proc- 
esses, and  not  from  gall-stones  as  such,  that  these  perils  supervene, 
and  hence  the  clinical  importance  of  that  unfailing  sign  of  a  bacterial 
toxemia — fever.  When  such  a  fever  cannot  be  traced  to  other  toxins, 
such  as  tuberculosis  or  rheumatism,  and  signs  of  cholelithiasis  coexist, 
the  physician  should  not  delay  having  recourse  to  the  surgeon;  his 


CHOLELITHIASIS,    CHOLECYSTITIS,   AND    STENOSIS  405 

decision  being  based  not  so  much  on  the  degree  of  the  fever  as  on  its 
persistence.  Lately,  a  physician  consulted  me  for  obscure  hepatic 
pains,  accompanied  by  four  months'  fever,  which  had  been  daily  noted 
with  at  hermometer.  Though  the  temperature  range  had  never  been 
high,  and  the  patient  kept  about  the  whole  time,  yet  empyema  of  the 
gall-bladder  was  found  at  the  operation  in  time  to  save  life.  I  believe 
also  that  in  every  case  of  those  terrible  accidents  when  a  gall-bladder 
or  duct  bursts,  and  gall-stones  with  infected  fluid  make  their  way  out 
into  the  peritoneum,  or  with  their  consequent  perils,  the  preceding 
fever  may,  though  present,  have  been  overlooked. 

The  history  of  chills  is  not,  by  itself,  conclusive  of  suppurative 
processes,  as  these  often  occur  in  ordinary  attacks  of  biliary  colic,  but 
chills,  accompanied  by  a  persistent  febrile  condition,  are  of  more 
serious  import. 

When  impacted  stones  as  such  furnish  the  reason  for  resorting  to 
operation  the  symptoms  are  usually  definite  enough.  The  first  to 
mention  is  complete  occlusion  of  the  cystic  duct,  usually  by  a  single 
large  calculus.  The  gall-bladder  then  swells,  as  already  described,  into 
a  palpable  and  sometimes  very  large  tumor,  caused  by  secretion  from 
its  walls.  When  that  occurs  there  is  little  chance  of  a  spontaneous 
change  in  the  location  of  the  calculus,  and  meantime  there  is  danger  of 
an  infective  cholecystitis  from  bacteria  reaching  it  through  the  blood. 
Nothing  but  a  surgical  operation  can  be  expected  to  relieve  this  con- 
dition. 

The  second  condition  requiring  operation  is  in  cases  of  chronic  ob- 
structive jaundice  from  impaction  by  one  or  more  calculi  in  the  com- 
mon duct.  Chronicity  is  the  chief  guide  here  for  diagnosis  and  treat- 
ment. Naun3rn  very  justly  states  that  a  jaundice  lasting  more  than  a 
year  is  almost  surely  due  to  gall-stones,  because  new  growths  causing 
jaundice  wiU  show  further  progress  in  other  symptoms  in  less  time  than 
that.  As  before  remarked,  gall-stone  jaundice  usually  varies  in  degree 
from  time  to  time,  while  jaundice  from  tumor  pressure  does  not. 
While  the  liver  may  be  enlarged  with  elongation  of  the  right  lobe,  the 
gall-bladder,  in  obstructive  gall-stone  jaundice,  may  shrink  up  to  the 
size  of  a  walnut.  The  refractory  nature  to  medical  means  of  these  long- 
retained  calculi  in  the  common  duct  is  because  they  become  coated  with 
bilirubin  calcium,  locally  produced  by  chronic  inflammation  of  the 
walls  of  the  duct,  until  they  actually  resemble  stones  in  hardness.  If, 
therefore,  a  few  months  of  systematic  medical  treatment  does  not  seem 
appreciably  to  relieve  such  a  case,  an  operation  should  be  advised,  not 
only  to  forestall  local  accidents,  but  to  save  the  liver  from  that  biliary 


406  CLINICAL  MEDICINE 

cirrhosis  which  supervenes  upon  long-standing  occlusion  of  the  common 
duct.  In  some  cases  an  operation  may  show  that  the  obstruction  is 
due  to  stenosis  of  the  common  duct,  caused  by  antecedent  inflammatory 
processes  around  it, 

CIRRHOSIS  OF  THE  LIVER 

This  affection  assumes  different  forms  which  vary  in  their  causa- 
tion and  their  course.  One  form  which  illustrates  a  remark  already 
made,  that  the  liver  performs  more  than  one  function  whose  etiology 
is  but  little  known,  is  well  exempUfied  in  a  marked  cirrhosis  of 
the  liver  found  in  all  cases  in  which  there  is  a  congenital  absence 
of  the  lenticular  nucleus  in  the  corpus  striatum.  This  nucleus  is 
embedded  in  one  of  the  most  distinctly  motor  regions  at  the  base  of 
the  brain,  and  its  absence  has  been  reported  in  14  cases,  all  of  them 
accompanied  by  definite  symptoms  in  various  parts  of  the  body,  but 
with  one  accompaniment  which  is  difficult  to  account  for,  namely, 
cirrhosis  of  the  Hver.  How  a  virtually  brain  lesion  should  cause 
cirrhosis  of  the  liver  I  have  no  idea.  (See  "Brain,"  Nov.,  191 2,  Dr. 
Kinnier's  article  on  "Progressive  Lenticular  Degeneration.")  All 
forms  of  cirrhosis  of  the  liver  have  one  characteristic  in  common, 
namely,  an  excess  of  connective  tissue  throughout  the  organ,  and  the 
accompanying  morbid  symptoms  can  be  directly  ascribed  to  this 
change. 

Alcoholic  Cirrhosis 

One  of  the  most  frequent  examples  of  the  kind  is  found  in  what  is 
termed  "alcohohc  cirrhosis  of  the  Hver,"  in  fact,  the  term  "cirrhosis" 
was  first  applied  by  Laennec  to  this  particular  affection,  but  is  now 
more  widely  appHed  to  analogous  changes  in  which  fibrous  tissue  is 
increased  in  various  organs,  such  as  the  lungs  and  kidneys,  without  any 
reference  to  alcohol.  In  nervous  tissue  the  term  for  this  change  is 
"sclerosis."  It  may  be  stated,  as  a  rule,  that  when  the  cells  proper  to 
any  tissue  so  lose  their  vitality  that  they  die,  the  omnipresent,  but  less 
vital,  connective  tissue  takes  the  place  of  the  more  living  cells  of  the 
parenchyma  of  the  organ. 

There  is  no  agent  which  so  devitalizes  Hving  cells  as  alcohol. 
When  it  is  present  in  any  considerable  amount  in  the  tissues,  but 
notably  in  glandular  and  nervous  tissues,  it  first  causes  premature 
aging  of  the  cells  and  then  their  death.  It  should  be  borne  in  mind, 
however,  that  this  action  of  alcohol  is  in  proportion  to  its  concentra- 
tion. Alcoholic  drinks  taken  upon  an  empty  stomach  will  pass  directly 
to  the  liver  and  affect  its  cells  accordingly.     On  that  account,  one  of 


ALCOHOLIC   CIRRHOSIS  407 

the  worst  habits  of  topers  is  to  order  the  American  cocktail,  which  is 
commonly  taken  before  any  food,  and  I  have  known  of  more  cases  of 
cirrhosis  of  the  liver  thus  produced  than  in  any  other  class  in  private 
practice. 

The  usual  change  that  we  find  in  the  liver  at  autopsy  is  that  the 
organ  is  much  reduced  ui  size,  sometimes  to  one-quarter  its  normal 
bulk.  Along  with  this,  the  surface  is  quite  nodular,  so  as  to  give  origin 
to  the  old  term  "hobnail  liver."  The  hver  tissue  is  hard,  and  cuts 
more  like  cartilage,  presenting  yellow  and  white  patches,  the  first 
representing  the  shrunken  hver-tissue,  and  the  paler  patches  connective 
tissue.  But,  besides  destruction  of  Hver  cells,  there  is  great  obUtera- 
tion  of  the  capillaries  of  the  portal  system,  leading  to  two  results,  the 
first  being  the  estabHshment  of  compensatory  channels  of  the  circula- 
tion outside  the  Hver,  and  the  second  to  a  dropsical  effusion  into  the 
peritoneum.  Like  all  forms  of  edema,  the  mechanism  of  this  ascites  is 
not  clear. 

The  compensatory  circulation  is  usually  readily  demonstrated. 
It  is  ordinarily  carried  out  by  the  following  set  of  vessels:  The  acces- 
sory portal  system  of  Sappey,  of  which  important  branches  pass  in 
the  round  and  suspensory  Hgaments  and  unite  with  the  epigastric  and 
mammary  systems.  These  vessels  are  numerous  and  small.  Occa- 
sionally a  large  single  vein,  which  may  attain  the  size  of  the  Httle 
finger,  passes  from  the  hilus  of  the  Kver,  follows  the  round  ligament, 
and  joins  the  epigastric  veins  at  the  navel.  Although  this  has  the 
position  of  the  umbihcal  vein,  it  is  instead  an  enlarged  vein  alongside 
the  obliterated  umbilical  vessel.  There  may  also  be  produced,  but 
not  very  commonly,  about  the  navel  a  bunch  of  varices,  the  so-called 
caput  medusa.  Other  branches  of  this  system  occur  in  the  gastro- 
epiploic omentum  about  the  gall-bladder,  and,  most  important  of  all, 
in  the  suspensory  ligament.  These  latter  form  large  branches  which 
anastomose  freely  with  the  diaphragmatic  veins,  and  so  unite  with  the 
vena  azygos;  again,  by  the  anastomosis  between  esophageal  and  gas- 
tric veins.  Veins  at  the  lower  end  of  the  esophagus  may  be  enor- 
mously enlarged,  producing  varices  which  project  on  the  mucous  mem- 
brane. Besides  these,  there  are  communications  between  the  hemor- 
rhoidal and  the  inferior  mesenteric  veins.  There  are  numerous  other 
channels  which  are  not  constant,  but  when  they  exist  they  may  enlarge 
so  as  to  form  retroperitoneal  anastomosing  channels. 

The  time  occupied  in  establishing  these  various  vessels  of  collateral 
circulation  varies  in  different  individuals.  If  the  compensatory  cir- 
culation is  early  established  it  is  remarkable  how  comfortable  the 


408  CLINICAL  MEDICINE 

patients  may  remain  for  long  periods,  but  the  rule  is  that  different 
morbid  symptoms  appear  in  all  the  viscera  connected  with  the  portal 
circulation. 

Symptoms. — Among  the  earUest  are  the  gastric  symptoms,  the 
patients  soon  showing  great  disincUnation  for  soHd  food  because  of  its 
slow  digestion.  This  is  characteristic  of  chronic  alcohoHcs,  until 
finally  they  may  take  only  small  quantities  of  any  nutriment.  I  have 
been  struck  with  the  fact  that  but  few  cases  of  delirium  tremens  take 
food  for  a  week  before  their  attacks.  Others  are  continually  complain- 
ing of  heaviness,  and  especially  flatulence,  after  eating.  The  bowels 
are  either  constipated  or  with  frequent  small  passages.  Pains  in  differ- 
ent parts  of  the  abdomen  are  complained  of,  which  in  some  cases  are 
due  to  localized  peritonitis.  It  is  striking  on  postmortem  examina- 
tion to  find  how  often  the  intestines  are  matted  together  by  bands 
formed  during  such  attacks.  But  another  element  comes  in,  and  that 
is  the  frequency  of  tuberculous  infection  which  may  occur  in  the 
pleura  also.  A  part  of  the  ascites  present  in  these  cases  may  follow 
upon  tuberculous  peritonitis,  but  the  dropsical  effusion  in  them  is 
never  so  great  as  when  due  primarily  to. obstruction  in  the  portal  cir- 
culation itself.  When  the  ascites  is  so  extreme  that  it  must  be  reheved 
by  tapping,  the  days  of  the  sufferers  are  numbered,  for,  though  this 
procedure  may  prolong  life  by  relieving  the  kidneys  from  mechanical 
pressure,  yet  there  is  no  other  chronic  disease  whose  prognosis  is  so  un- 
favorable. Death  usually  occurs  within  less  than  a  year  from  the 
first  symptom. 

As  the  hemorrhoidal  veins  are  the  lowest  branches  of  the  portal 
system  it  is  natural  that  these  should  be  affected  in  all  forms  of  hepatic 
cirrhosis.  Hemorrhoids  are,  therefore,  nearly  always  present,  and 
sometimes  they  are  very  troublesome. 

In  alcoholic  cirrhosis,  with  contracted  liver,  hemorrhage  is  common. 
The  bleeding  may  come  from  the  branches  of  enlarged  veins  at  the 
lower  end  of  the  esophagus,  when  it  may  occasion  free  vomiting  of 
blood  as  well  as  blackening  of  the  feces.  However  profuse,  it  is  seldom 
fatal,  and  is  very  apt  to  recur. 

It  is  otherwise  with  bleeding  from  the  intestines.  One  case  under 
my  observation  bled  to  death  while  at  stool.  Another,  a  prominent 
city  ofi&cial,  dropped  dead  in  the  street.  At  autopsy  it  seemed  as  if 
all  the  blood  in  his  body  had  accumulated  in  his  intestines,  both  small 
and  large,  while  none  appeared  outside.  Bleeding  may  aften  occur 
from  the  bowels  without  hematemesis,  and  there  may  also  be  epistaxis, 
which  is  a  sure  sign  of  advancing  toxemia. 


SYPHILITIC  CIRRHOSIS  409 

Meantime  the  aspect  of  the  patient  is  often  very  characteristic. 
He  is  thin,  eyes  sunken,  with  a  sallow,  muddy  complexion,  and  occa- 
sionally actually  jaundiced,  the  conjunctiva;  watery,  with  patches  of 
distended  veins  on  the  nose  and  cheeks.  Patches  of  distended  veins 
resembhng  nevi  may  be  found  on  the  face,  neck,  and  back,  or  the  veins 
may  coalesce,  along  with  areas  accompanied  by  erythematous  discol- 
orations.  Though  there  may  be  edema  of  the  feet  the  dropsy  is  not 
general. 

The  cause  of  death  in  alcoholic  cirrhosis  is  from  brain  poisoning. 
The  patients  generally  first  pass  into  a  noisy  or  muttering  delirium, 
ending  in  coma.  This  condition  is  often  mistaken  for  uremia,  which  it 
much  resembles,  but  there  are  really  only  a  few  of  the  most  character- 
istic symptoms  of  uremia  present,  as  they  are  rather  approximate  to 
those  of  cholemia  found  in  fatal  cases  of  jaundice. 

Treatment. — The  treatment  of  fully  estabHshed  alcoholic  cirrhosis 
with  ascites  is,  as  we  have  remarked,  very  unpromising.  I  have  no 
doubt,  however,  that  I  have  prolonged  Ufe  in  some  cases  by  stimulation 
of  the  circulation  in  the  liver  by  external  applications.  One  of  these 
is  by  free  faradization  of  the  skin  of  the  abdomen,  one  pole  with  moist 
sponges  being  appHed  between  the  shoulder-blades,  and  the  other 
passed  back  and  forth  over  the  anterior  surface  of  the  abdomen,  to  be 
followed  by  douching  of  the  abdomen  by  means  of  large  sponges  filled 
with  water  and  then  squeezed  at  a  height  of  18  inches  above  the  ab- 
domen. These  measures  should  not  be  tried  imtil  after  the  patient 
has  been  tapped.  The  bowels  should  be  acted  upon  every  day  by 
doses  of  40  gr.  of  the  compound  jalap  powder.     Diuretics  are  useless. 

Fatty  Cirrhotic  Liver 

In  all  cases  of  cirrhosis,  even  in  the  atrophic  form,  there  is  a  con- 
siderable amount  of  fat  in  the  interstices  of  the  Uver  tissue.  In  many 
cases  the  organ,  instead  of  being  atrophied,  appears  to  be  uniformly 
enlarged.  At  autopsy,  while  the  connective  tissue  is  much  increased, 
there  is  a  general  fatty  infiltration  between  the  cells,  the  organ  appear- 
ing to  be  anemic  and  with  a  yellowish  color  very  similar  to  true  fatty 
liver.     This  form  is  particularly  common  among  beer  drinkers. 

Syphilitic  Cirrhosis 

I  would  allude  here  to  affections  of  the  liver  in  acquired  syphilis 
among  adults  and  not  to  congenital  syphiHs  in  infants.  It  is  remark- 
able how,  in  infants  dymg  from  prenatal  syphiHs  or  soon  after  birth,. 


4IO  CLINICAL  MEDICINE 

their  liver  shows  a  greater  abundance  of  the  Spirochaeta  pallida  than 
in  any  syphilitic  lesions  in  adults. 

In  acquired  syphilis,  on  the  other  hand,  we  may  find  the  Hver  more 
distorted  than  in  any  other  complaint.  I  once  observed  in  a  hospital 
patient  that  his  Hver  seemed  to  be  divided  by  great  bands  of  connective 
tissue,  much  as  a  pillow  can  be  tied  up  by  cords. 

These  bands  are  ordinarily  produced  by  syphilitic  gummata,  which 
may  have  disappeared  and  left  behind  them  streaks  of  connective 
tissue.  In  other  cases,  however,  the  syphiHtic  gummata  produce  large 
tumors  that  may  attain  the  size  of  an  orange,  surrounded  by  a  zone  of 
infiltrated  tissue,  which  may  radiate  in  many  different  directions.  By 
this  means  a  true  syphilitic  cirrhosis  of  liver  tissue  may  be  generated, 
the  process  sometimes  being  localized  with  caseous  degeneration  at  the 
center  of  the  mass.  In  some  cases  this  softens  in  time  and  becomes 
charged  with  calcareous  salts.  If  the  syphilitic  nature  of  the  growth  is 
not  recognized  it  may  be  easily  confounded  with  cancer.  On  the 
other  hand,  this  cirrhotic  condition  may  be  so  widely  spread  that  it 
gives  rise  to  ascites  which  requires  frequent  tapping,  but,  notwith- 
standing the  extensive  and  grave  changes  in  the  liver,  the  prognosis  is 
totally  different  from  that  of  any  other  form  of  cirrhosis,  for  the  most 
pronounced  alterations  will  give  way  and  disappear  under  the  admin- 
istration of  potassium  iodid,  and  the  liver  be  restored  to  its  usual  condi- 
tion. The  doses  of  the  iodid,  as  in  other  tertiary  lesions,  must  be  large, 
as  much  as  140  gr.  a  day  being  administered  in  divided  doses.  These 
doses  should  always  be  regulated  according  to  the  supervention  of  the 
symptoms  of  iodism,  for  so  soon  as  they  appear  the  dose  should  be 
diminished  or  else  suspended  altogether.  The  S3anptoms  of  iodism 
are  first  a  catarrh  of  the  nose  and  throat,  sometimes  quite  painful. 
The  patients  may  then  pass  into  a  febrile  state,  with  loss  of  flesh  and 
general  debility,  soon  to  recover,  however,  on  modification  or  suspen- 
sion of  the  dose  of  the  drug. 

As  might  be  expected  from  its  direct  relation  to  the  portal  circu- 
lation, the  spleen  is  always  enlarged  in  cases  of  cirrhosis  of  the  liver. 
This  enlargement  may  be  even  more  pronounced  than  that  of  the  hver 
itself  in  hypertrophic  cases  and  sometimes  feels  very  hard. 

Cirrhosis  of  the  Hver  occurs  in  children.  Occasionally,  this  hap- 
pens in  alcohoHc  cases,  as  in  some  German  famihes  the  children  are 
given  beer  to  drink.  It  may  also  occur  as  a  primary  stage  of  Hanot's 
hypertrophic  cirrhosis.  Its  management  differs  in  no  respect  from 
that  of  the  other  forms  of  cirrhosis  of  the  Hver  which  we  have  been 
considering. 


hypertrophic  cirrhosis  4ii 

Hypertrophic  Cirrhosis 

This  disease  was  first  fully  described  by  Hanot  in  1875,  and  has 
since  gone  by  his  name.  It  is  a  puzzle,  as  no  cause  can  be  assigned  for 
it.  Thus,  alcohol  plays  no  part  in  its  genesis,  as  the  patients  rarely 
give  any  history  of  addiction  to  either  spirits  or  beer.  The  patients 
are  young,  and  of  an  earlier  age  than  in  most  drunkards.  There  is  a 
remarkable  preponderance  of  males — 22  out  of  Schachman's  26  cases. 
The  course  of  the  disease  is  very  chronic,  much  more  so  than  in  alco- 
holics, as  it  may  last  for  six  or  even  ten  years.  There  is  no  ascites  and 
no  dilatation  of  the  subcutaneous  veins.  It  is  not  accompanied  by 
either  general  or  localized  peritonitis,  for  there  are  no  adhesions.  It 
is  more  like  a  subacute  parenchymatous  inflammation  of  the  whole 
organ,  for  there  is  often  marked  leukocytosis  with  the  connective  tissue, 
abounding  with  small  round  cells.  Jaundice  is  usually  slight,  except 
in  the  terminal  stages.  There  is  bile  in  the  urine,  and  the  stools  are 
not  clay  colored  as  in  obstructive  jaundice.  There  is  no  question 
about  its  being  a  cirrhosis,  for  liver  nodules  are  seen  everywhere,  sepa- 
rated by  bands  of  connective  tissue.  On  the  other  hand,  the  Hver  cells 
proper  are  neither  fatty  nor  pigmented  and  may  be  increased  in  size. 
The  bile  vessels,  however,  are  the  seat  of  a  general  cholangitis  and  so 
surrounded  by  new  connective  tissue  that  this  affection  has  been 
termed  "a  biliary  cirrhosis." 

Among  the  common  chnical  symptoms  are  attacks  of  pain  referred 
to  the  region  of  the  liver.  These  attacks  occur  from  time  to  time,  and, 
when  severe,  may  be  accompanied  with  nausea  and  vomiting.  The 
jaundice  may  deepen  after  these  attacks.  The  hver  itself  is  always 
enlarged  and  may  extend  down  to  the  navel,  its  lower  edge  being  easily 
made  out  and  hard.  The  patients  complain  greatly  of  itching  of  the 
skin,  which  may,  as  in  other  forms  of  jaundice,  be  the  seat  of  urticaria 
or  purpuric  blotches,  if  not  of  dark  pigmented  patches.  As  might  be 
expected,  hemorrhages  are  frequent,  and,  when  severe  and  recurrent, 
may  be  one  cause  of  death.  But  the  usual  fatal  termination  is  by 
cholemia,  as  in  cases  of  fatal  jaundice. 

Treatment. — If  seen  during  the  ordinary  course  of  the  disease,  be- 
fore the  terminal  cholemia,  much  may  be  done  by  active  treatment 
in  the  fashion  recommended  for  choleHthiasis.  A  patient  came  to 
my  office  for  hepatic  pains  that  were  not  paroxysmal,  with  a  uniformly 
enlarged  liver  and  jaundice,  but  without  any  history  of  bihary  cohc. 
An  exploratory  operation  had  been  performed  at  one  of  our  leading 
hospitals,  but  nothing  wrong  had  been  found  in  his  gall-bladder  or  in 
the  cystic  or  common  duct.     He  was  treated  with  10  gr.  of  sodium 


412  CLINICAL  MEDICINE 

benzoate  and  sodium  salicylate,  four  times  a  day,  with  a  mercurial 
purge  twice  a  week,  and  2  oz.  of  olive  oil  in  hot  milk  every  night. 
He  at  once  began  to  improve,  and  has  continued  so  up  to  date. 

PYLEPHLEBITIS 

This  affection  as  a  separate  condition  cannot  be  diagnosed  during 
life,  and  can  be  suspected  only  when  sudden  engorgement  of  the  main 
branches  of  the  portal  vein  develops  without  being  preceded  by  the 
usual  s3miptoms  which  attend  chronic  embarrassment  of  the  hepatic 
circulation,  as  in  a  cirrhosis  of  the  liver. 

ABSCESS  OF  THE  LIVER 

Suppuration  in  the  substance  of  the  liver  may  occur  from  various 
causes.  We  have  already  alluded  to  a  widespread  infective  cholan- 
gitis which  may  supervene  on  the  irritation  of  gall-stones,  and  in  which 
the  abscesses  are  small  but  very  numerous.  Likewise,  in  speaking  of 
amebic  dysentery,  we  have  mentioned  the  single  large  abscess  in  the 
liver  which  follows  ulcerative  inflammation  of  the  large  bowel,  and 
whose  nature  is  revealed  by  the  presence  of  the  specific  ameba  in  the 
pus  of  the  abscess.  This  liver  abscess  often  occurs  among  Europeans  in 
India. 

The  most  common  cause  in  this  country  of  liver  abscesses  is  from 
infections  through  branches  of  the  portal  system,  and  classed  under 
the  term  "pylephlebitis."  Any  ulcerative  process  going  on  in  the 
rectum,  or  abscesses  in  the  pelvis  or  abscesses  accompanying  appendi- 
citis, may  lead  to  the  formation  of  numerous  collections  of  pus  in  the 
liver. 

But  we  may  have  a  single  large  abscess  instead.  I  once  called  a 
well-known  surgeon  to  operate  on  a  patient  who  presented  the  follow- 
ing characteristic  symptoms.  He  had  long  been  affected  with  an 
irregular  fever,  when  the  temperature,  from  being  normal,  would 
suddenly  rise  to  103°  or  104°  F.,  often  with  a  rigor,  and  after  the 
fever  he  had  profuse  sweats. 

The  liver  was  enlarged  and  tender,  and  the  patient  always  preferred 
to  He  on  the  right  side  to  prevent  a  dragging  pain,  which  came  on  if  he 
turned  to  the  left.  He  never  had  dysentery  nor  lived  in  a  tropical 
country.  The  patient  looked  septic  and  the  pulse  remained  high, 
whether  he  had  fever  or  not.  To  my  chagrin,  the  surgeon  made  a  long 
incision  in  the  median  line  in  front,  into  which  he  passed  his  whole 
hand,  and  felt  the  under  as  well  as  the  upper  surface  of  the  Hver  without 
finding  any  sign  of  fluctuation.     After  he  had  sewed  the  incision  up  I 


ACUTE   YELLOW   ATROPHY    OF    THE   LIVER  413 

told  him  to  introduce  a  trocar  into  the  liver  under  the  right  scapula. 
This  caused  an  immense  abscess  to  be  tapped  there.  I  mention  this 
case  to  illustrate  the  cHnical  fact  that  single  large  hepatic  abscesses 
are  generally  in  the  right  lobe  and  situated  above  and  posteriorly,  which 
in  this  case  was  rendered  more  probable  by  a  small  patch  of  pleurisy 
just  below  the  scapula. 

Hydatids  may  occur  in  any  part  of  the  body,  and  hence  in  any  part 
of  the  liver.  The  cysts  which  they  form  in  the  Uver  may  suppurate  and 
cause  large  single  abscesses,  whose  pus  may  then  burrow  in  any  direc- 
tion. I  was  once  consulted  for  persistent  vomiting  in  a  woman,  and, 
on  examining  the  matter  ejected,  found  numerous  hooks  of  the  echi- 
nococcus.  A  Hver  abscess  had  first  formed,  which  had  then  burst  into 
the  stomach.     This  patient  in  time  recovered. 

ACUTE  YELLOW  ATROPHY  OF  THE   LIVER 

The  essential  cause  of  this  fortunately  uncommon  disease  is  un- 
known. All  we  can  do  is  to  enumerate  its  most  frequent  antecedents. 
One  of  the  earUest,  as  well  as  one  of  the  best  descriptions,  is  by  the 
great  physician  Bright,  who,  in  1836,  described  it  as  a  diffuse  inflam- 
mation of  the  substance  of  the  Kver  affecting  the  glandular  substance 
more  than  the  connective  tissue,  leading  to  marked  diminution  in  the 
size  of  the  organ,  causing  jaundice  associated  with  severe  nervous  symp- 
toms and  a  special  tendency  to  hemorrhage. 

It  may  occur  at  any  age,  but  is  very  rare  under  ten.  Women, 
however,  greatly  preponderate  over  men,  and  among  women  the 
greater  number  are  attacked  during  pregnancy  or  soon  after  parturi- 
tion. The  only  case  that  I  have  seen  was  that  of  a  primipara  who 
gave  birth  to  healthy  twins.  Within  a  week  after  parturition  she 
began  to  be  jaundiced,  with  incessant  vomiting  but  without  fever  until 
the  last  few  days,  when  slight  febrile  symptoms  set  in.  Hemorrhage 
under  the  skin,  however,  developed  in  various  parts.  The  diagnosis 
was  made  early  on  account  of  the  shrinking  of  liver  dulness  on  per- 
cussion. In  this  disease  the  liver  has  been  found  after  death  reduced 
to  one-fourth  its  normal  size,  and  leucin  and  tyrosin  appear  in  the 
urine.  When  jaundice  sets  in  it  may  be  either  gradual  or  sudden  in 
its  onset,  but  at  last  severe  nervous  symptoms  develop,  such  as  violent 
headache,  muscular  trembling,  and  convulsions  ending  in  death,  pre- 
ceded usually  by  profound  coma.  The  disease  evidently  is  due  to  a 
severe  toxemia,  whose  origin  and  nature  as  yet  are  quite  unknown, 
while  no  successful  means  for  treatment  has  been  devised. 


414  CLINICAL   MEDICINE 

AMYLOID  DEGENERATION 

Amyloid  degeneration  when  it  occurs  is  a  widespread  change  in 
the  tissues,  involving  a  great  many  organs,  and  is  in  some  way  con- 
nected with  conditions  of  chronic  suppuration,  hence  it  is  not  infre- 
quent after  the  formation  of  phthisical  cavities.  This  is  well  illustrated 
in  amyloid  degeneration  of  the  liver,  when  this  organ  may  be  enor- 
mously enlarged.  Wilkes  speaks  of  such  a  hver  weighing  14  pounds. 
Its  appearance  is  then  so  characteristic  that  it  has  been  called  the 
waxy  or  lardaceous  liver. 

Amyloid  degeneration  of  the  kidneys  is  not  a  form  of  trae  B right's 
disease,  though  in  its  effects  and  symptoms  it  may  closely  resemble  it. 
The  kidney  alterations  are  only  an  accompaniment  of  the  amyloid 
degeneration  in  other  organs,  and  in  all  forms  of  chronic  suppuration 
whatever  its  cause.  What  the  connection  is  between  suppurative 
processes  and  amyloid  degeneration  we  do  not  know. 

In  one  of  my  patients  the  continued  formation  of  abscesses,  orig- 
inally starting  from  alceration  of  the  appendix,  led  to  amyloid  de- 
generation in  various  organs  and  parts  of  the  body  when  he  was  a 
young  man.  When  the  kidneys  are  affected  we  may  have  an  abundant 
flow  of  highly  albuminous  urine,  with  many  of  the  symptoms  of 
parenchymatous  nephritis.  In  such  cases  it  may  impHcate  the  ali- 
mentary canal  and  cause  vomiting  and  diarrhea.  As  this  disorder 
supervenes  upon  serious  antecedent  affections,  little  can  be  hoped 
for  by  any  measures  of  treatment.  Postmortem  amyloid  change  is 
discovered  in  the  tissues  by  the  characteristic  reactions  with  the 
tincture  of  iodin,  showing  spots  of  a  peculiar  mahogany-brown  color. 

Treatment. — Medicinally,  10  gr.  of  urotropin  should  be  admin- 
istered three  or  four  times  a  day,  with  the  sodium  benzoate  as  before 
mentioned.     (See  page  235.) 

MOVABLE  LIVER 

This  is  a  term  applied  to  virtually  dislocated  portions  of  the 
organ  brought  about  by  external  pressure,  such  as  by  tight  lacing 
in  women.  A  really  movable  liver,  similar  to  a  movable  kidney,  is 
impossible,  as  the  organ  is  so  connected  at  its  posterior  margin  with 
the  inferior  vena  cava  and  diaphragm  that  any  great  mobihty  from 
this  point  is  out  of  the  question. 


CHAPTER    VIII 
DISEASES  OF   THE   SPLEEN 

The  spleen  is  an  organ  present  in  all  mammals  from  early  embry- 
onic life.  What  its  functions  are,  however,  is  quite  undetermined. 
It  is  well  demonstrated  that  it  is  not  necessary  to  life  or  even  to  well- 
being,  for  it  has  been  wholly  removed,  both  experimentally  in  animals 
and  in  man,  without  injury  to  the  general  health.  It  would  seem, 
therefore,  that  an  organ  which  is  not  missed  when  absent  cannot  be  of 
great  importance  when  it  is  present.  When,  for  any  cause,  it  becomes 
diseased  it  may  be  an  actual  advantage  to  the  body  to  remove  it  alto- 
gether. These  facts  give  color  to  the  remark  of  an  old  anatomist, 
that  the  business  of  the  spleen  was  simply  to  fill  up  a  hole  under  the 
left  arch  of  the  diaphragm. 

The  spleen  is  prone  to  become  enlarged  or  hypertrophied  in  all 
cases  where  the  liver  is  similarly  involved,  but  it  frequently  becomes 
hypertrophied  on  its  own  account,  thus  splenomegaly  is  often  found  in 
chronic  malaria,  so  as  to  give  the  name  of  ague-cake,  when  it  may  be 
found  to  extend  below  the  umbilicus  in  front.  It  is  also  enlarged  in 
the  course  of  specific  fevers,  notably  in  typhoid,  and  in  leukemia,  one 
form  of  which  is  called  splenomedullary. 

When  the  spleen  is  itself  the  seat  of  disease,  as  in  Banti's  disease, 
which  ordinarily  besides  its  overgrowth  is  accompanied  by  anemia,  and 
a  tendency  to  hematemesis,  the  best  treatment  is  to  remove  the  organ 
altogether,  whereupon  the  general  health  rapidly  improves.  We  may 
say,  in  short,  that  the  spleen  seems  to  act  as  a  reservoir  of  waste  prod- 
ucts; thus,  it  is  supposed  to  be  largely  connected  with  the  final  de- 
struction of  worn-out  red  corpuscles,  and  by  many  is  supposed  to  be 
the  depositing  place  of  uric  acid  and  similar  waste  products.  In  the 
so-called  Banti's  disease  the  skin  is  prone  to  be  discolored  in  extensive 
patches,  and  if  it  occurs  in  childhood  bodily  growth  is  interfered  with. 

Polycythemia  is  a  condition  in  which,  with  an  enlarged  spleen  and 
cyanosis,  there  is  an  extraordinary  increase  in  the  number  of  the  red 
blood-corpuscles,  up  to  9,000,000  to  13,000,000  per  c.mm.  Headache, 
giddiness,  and  constipation  are  the  common  symptoms.  The  patient, 
especially  when  it  is  cold,  may  appear  very  cyanotic.  This  may  last 
for  many  years  without  seriously  affecting  the  health.  Its  etiology 
is  v/hoUy  unknown. 

41.5 


CHAPTER    IX 
DISEASES  OF  THE  PANCREAS 

No  single  gland  in  the  body  compares  with  the  pancreas  in  the 
varied  properties  and  activity  of  its  secretion;  that  secretion  acts 
upon  the  proteins,  the  fats,  and  the  starches,  digesting  them  all. 

In  our  discussion  of  the  etiology  of  gastroduodenal  ulcers  we  re- 
ferred to  the  question  why  the  stomach  does  not  digest  itself.  This 
question  is  even  more  natural  in  the  case  of  the  pancreas,  with  its  more 
powerful  and  varied  secretions,  and,  in  fact,  such  autodigestion  of 
the  pancreas  is  found  in  fully  50  per  cent,  of  all  cases  after  death,  while 
the  stomach  is  found  so  only  when  death  occurs  during  digestion. 
We  shall  see  that  in  75  per  cent,  of  cases  of  death  from  lesions  of  the 
pancreas  itself  a  preceding  autodigestion  was  the  cause  of  the  fatal 
issue.  It  is  fortunate,  however,  that  this  accident  is  uncommon, 
though  why  so  is  difficult  to  explain,  except  on  the  same  principle, 
as  in  the  case  of  the  stomach,  that  the  system  generates  antibodies, 
such  as  antipepsins,  antitrypsins,  etc. 

The  situation  of  this  gland  is  in  the  epigastrium,  with  the  stomach 
above  and  the  transverse  colon  below.  Its  secretion  in  man  is  Hmpid 
and  colorless,  always  alkaline  in  reaction,  with  a  specific  gravity  of 
1.0075.  I^  ^11  mammals  it  is  one  of  the  most  abundant  secretions  in 
the  body,  amounting  in  the  cow  to  between  i|  liters,  and  in  man  from 
500  to  800  c.c.  per  diem,  according  to  the  food  taken.  In  man  it  enters 
the  duodenum  by  one  duct,  called  the  duct  of  Wirsung,  entering 
the  intestine  conjointly  with  the  bile,  descending  through  the  common 
bile-duct,  which  has  a  shght  dilatation  at  its  end  called  the  ampulla 
of  Vater.  This  fact  explains  why  so  many  enlargements  of  the  head 
of  the  pancreas,  such  as  by  tumor  or  cyst,  are  accompanied  by  jaun- 
dice. Another  important  fact  connected  with  the  pancreas  is  that  it 
contains  separate  and  distinct  collections  of  special  cells,  which  con- 
stitute what  is  termed  the  "islands  of  Langerhans."  The  secretions 
of  these  islands  have  nothing  to  do  with  the  pancreatic  secretion  coming 
off  through  the  duct  of  Wirsung,  for  they  discharge  their  secretions 
internally,  directly  into  the  blood.  These  secretions  have  an  impor- 
tant bearing  upon  the  changes  of  the  carbohydrates  into  sugar,  when 
disease  and  atrophy  of  these  structures  lead  directly  to  an  intractable 

416 


PANCREATIC   HEMORRHAGE  417 

form  of  diabetes  mellitus.  A  deficiency  in  the  pancreatic  secretion 
causes  the  stools  to  become  either  oily  in  consistence  or  grayish  in 
color.  In  some  cases  there  seems  to  be  a  total  inability  to  digest  the 
fats,  so  that  they  constitute  a  large  portion  of  the  feces.  There  is, 
however,  a  remarkable  variabihty  among  different  persons  in  their 
powers  to  deal  with  fats.  Some  may  show  large  quantities  of  undi- 
gested fats  in  their  stools  for  many  years  without  appearing  to  be 
out  of  health. 

Failure  in  pancreatic  secretion  also  shows  the  presence  of  undigested 
protein  or  meats  in  the  stools.  While  5  or  6  per  cent,  of  the  undigested 
proteins  in  the  feces  is  of  no  moment,  in  pancreatic  disease  the  undi- 
gested proteins  may  amount  to  from  30  to  40  per  cent,  in  the  stools. 
In  both  these  conditions,  whether  of  fat  or  protein  failure  of  diges- 
tion due  to  pancreatic  disease,  the  general  nutrition  soon  suffers. 

PANCREATIC  HEMORRHAGE 

We  now  turn  to  those  fatal  accidents  which  we  have  already 
referred  to  caused  by  the  autodigestion  of  the  pancreas  by  its  own 
secretion.  These  may  occur  as  a  direct  result  of  a  perforation,  by  a 
duodenal  ulcer,  or  from  obstruction  to  the  outflow  through  Wirsung's 
duct;  in  some  cases  possibly  by  regurgitation  of  bile  from  the  bile-duct. 
One  of  the  first  results  is  hemorrhage  into  the  substance  of  the  pan- 
creas, which,  if  due  to  autodigestion  of  a  large  artery  in  the  gland,  may 
be  the  speedy  cause  of  death.  When  the  bleeding  is  extensive  the 
entire  tissue  of  the  gland  may  be  destroyed,  and  the  hemorrhage  accu- 
mulates in  the  retroperitoneal  tissue.  The  patient  may  be  quietly 
resting,  when  he  is  suddenly  seized  with  a  very  severe  pain  referred 
to  the  upper  part  of  the  abdomen.  This  pain  steadily  increases  in 
severity,  and  is  accompanied  from  the  first  by  nausea  and  obstinate 
vomiting,  which  vomiting  gives  no  rehef.  The  patient  becomes  anx- 
ious, and  only  with  difficulty  can  be  restrained  in  bed.  The  body  is 
cold  and  the  forehead  is  covered  with  a  cold  sweat.  The  abdomen 
becomes  tender,  more  especially  in  the  epigastrium,  occasionally  with 
rapid  development  of  tympanites.  The  pulse  becomes  very  weak, 
small,  and  rapid  till  it  ceases  with  the  advent  of  death. 

Symptoms. — These  are  well  described  by  Prince  as  follows:  "The 
patient,  who  has  previously  been  quite  well,  is  suddenly  taken  with  the 
illness  which  terminates  his  life.  .  .  .  When  the  hemorrhage  occurs  the 
patient  may  be  quietly  resting  or  pursuing  his  usual  occupation.  The 
pain  which  ushers  in  the  attack  is  usually  very  severe  and  located  in 
the  upper  part  of  the  abdomen.     It  steadily  increases  in  severity,  is 

27 


4l8  CLINICAL   MEDICINE 

sharp,  or  perhaps  colicky,  in  character.  It  is  ahnost  from  the  first 
accompanied  by  nausea  and  vomiting;  the  latter  becomes  frequent  and 
obstinate,  but  gives  no  relief.  The  patient  soon  becomes  anxious, 
restless,  and  depressed;  he  tosses  about,  and  only  with  difficulty  can 
he  be  restrained  in  bed.  The  surface  is  cold  and  the  forehead  is  covered 
with  a  cold  sweat.  The  pulse  is  weak,  rapid,  and  sooner  or  later  im- 
perceptible. The  abdomen  becomes  tender,  the  tenderness  being 
located  in  the  upper  part  of  the  abdomen  or  epigastrium.  Tympanites 
is  sometimes  marked.  The  temperature  is  usually  normal  or  subnor- 
mal.    The  bowels  are  constipated." 

Another  striking  evidence  of  autodigestion,  to  which  we  have  re- 
ferred, is  found  postmortem  in  large  areas  of  fat  necrosis,  both  in  the 
pancreas  itself  and  in  the  surrounding  tissues,  such  as  in  the  mesentery, 
in  the  omentum,  in  the  abdominal  fatty  tissue  generally,  or  even  in  the 
pericardial  and  subcutaneous  fat.  These  necroses  show  a  dead  white 
color,  and  may  be  of  all  sizes,  both  very  small  and  quite  large.  When 
cut  into  and  examined,  besides  the  remains  of  fatty  tissue,  there  are 
always  found  lime  salts. 

ACUTE  PANCREATITIS 

In  some  cases  the  symptoms  which  we  have  described  are  preceded 
by  signs  of  acute  inflammation,  the  symptoms  of  which  are  charac- 
terized first  by  their  suddenness,  with  violent  colicky  pain,  in  the 
upper  part  of  the  abdomen  accompanied  by  nausea  and  vomiting. 

"Acute  pancreatitis  is  to  be  suspected  where  a  previously  healthy 
person,  or  a  sufferer  from  occasional  attacks  of  indigestion,  is  suddenly 
seized  with  a  severe  pain  in  the  epigastrium,  followed  by  vomiting  and 
collapse,  and,  in  the  course  of  twenty-four  hours,  by  a  circumscribed 
epigastric  swelHng.  Locahzed  tenderness  in  the  course  of  the  pan- 
creas and  tender  spots  throughout  the  abdomen  are  valuable  diag- 
nostic signs"  (Fitz).  In  some  cases  the  above-mentioned  lesions 
of  the  pancreas  lead  to  the  formation  of  a  localized  abscess.  In  other 
cases  instead  of  a  single  abscess  there  are  numerous  small  abscesses. 
It  is  always  a  suspicious  sign  to  find,  with  early  symptoms  of  this  con- 
dition, a  tumor-like  mass  in  the  epigastrium,  whereupon  a  laparotomy 
should  be  immediately  performed,  for  this  has  resulted  in  saving  life, 
even  when  extensive  fat  necrosis  surrounded  the  abscess.  The 
course  of  suppurative  pancreatitis  may  be  much  more  chronic  than  in 
the  acute  cases  above  mentioned.  But,  as  we  might  expect,  we  have 
also  gangrenous  pancreatitis  from  any  of  the  above  causes  of  pan- 
creatic lesions  which  we  have  mentioned.     Korte  has  collected  40 


PANCREATIC    CALCULI  419 

instances  in  literature.     Such  cases  end  in  collapse  and  death  in  from 
ten  to  thirty  days. 

Owing  to  the  numerous  small  passages  throughout  the  substance 
of  the  gland  for  secretion  it  is  natural  that  when  any  one  of  them  is 
closed  that  pancreatic  cysts  should  be  formed.  These  may  grow  quite 
rapidly  into  marked  rounded  tumors,  showing  fluctuation  from  their 
fluid  contents,  which  then  will  produce  local  symptoms  from  their 
pressure.  Once  in  my  hospital  service  I  had  a  patient  who  developed 
a  considerable  tumor,  situated  between  the  stomach  above  and  the 
transverse  colon  below.  This  tumor  was  not  displaced  by  the  descent 
of  the  diaphragm  during  inspiration,  which  fact  showed  that  it  was  not 
connected  with  the  liver.  Accompanying  the  tumor  was  intense 
jaundice  and  also  glycosuria.  I,  therefore,  diagnosed  it  as  being  a 
pancreatic  cyst,  formed  in  the  head  of  the  pancreas,  which  would 
account  also  for  the  jaundice.  I  had  the  patient  at  once  operated 
upon  by  my  surgical  colleague,  Dr.  McBurney,  who  drained  the  cyst, 
and  this  quickly  relieved  the  patient  of  his  jaundice  and  of  the  sugar  in 
his  urine,  so  that  he  made  a  rapid  recovery. 

CHRONIC  PANCREATITIS 

Some  of  the  cases  of  this  condition  are  remarkably  local  and 
wholly  devoid  of  symptoms,  so  that  it  may  not  be  discovered  until 
after  death.  Thus,  Mayo  Robson  reports  a  series  of  cases  in  which 
the  head  of  the  pancreas  was  so  hard  as  to  resemble  scirrhous  cancer, 
but  this  condition  may  be  strangely  compatible  with  good  health 
until  the  resulting  tumor  presses  upon  the  main  pancreatic  duct,  neces- 
sitating, therefore,  surgical  operation  to  restore  the  flow. 

Chronic  pancreatitis  occurs,  however,  in  two  forms,  one  of  which 
is  interlobular  and  the  other  interstitial,  leading  to  general  sclerosis 
of  the  gland.  It  is  remarkable  that  in  this  condition  the  islands  of 
Langerhans  frequently  escape,  so  that  diabetes  does  not  develop.  In 
other  cases,  however,  diabetes  does  result  from  these  structures  being 
involved,  though  it  is  strange  that,  if  only  a  few  of  the  islands  of 
Langerhans  escape  in  the  tail  of  the  pancreas,  that  those  few  cells  are 
still  sufficient  to  prevent  glycosuria,  as  we  have  already  remarked. 

PANCREATIC   CALCULI 

These  sometimes  form  in  the  duct  of  Wirsung.  The  concretions 
differ  altogether  from  biliary  calculi  in  that  they  are  composed  of 
carbonate  of  lime.  They  do  not  produce  any  characteristic  symptoms 
which  may  lead  to  their  diagnosis  during  life. 


CHAPTER  X 

DISEASES  OF  THE  URINARY  APPARATUS 

ACUTE  NEPHRITIS 

The  kidneys  are  the  most  paradoxic  organs  in  the  body,  in  a 
sense  that  gross  anatomic  lesions  may  occur  in  them  and  yet  produce 
results  just  the  opposite  from  those  we  would  naturally  expect.  Thus, 
J.  Rose  Bradford  removed  two-thirds  of  the  substance  of  each  kidney, 
but  the  remaining  third,  instead  of  showing  a  corresponding  loss  in  its 
functions,  excreted  much  more  urine  and  far  more  urea  than  would 
normal  kidneys.  The  only  explanation  would  seem  to  be  that  this 
injury  to  the  kidneys  started  a  general  breakdown  of  the  muscular 
tissues  into  urea,  which  is  the  final  outcome  of  muscular  metaboKsm. 
If  we  regard  the  elimination  of  urea  as  the  chief  function  of  the  kid- 
neys, this  experiment  would  at  first  sight  indicate  that  a  part  is  much 
larger  than  the  whole.  On  the  other  hand,  physiologists  have  demon- 
strated that  it  is  the  liver,  and  not  the  kidneys,  which  produces  urea, 
and  that  the  kidneys  simply  remove  the  urea  from  the  blood,  but  this 
experiment  indicates  that  the  small  portion  of  kidney  substance  left 
leads  to  a  great  increase  in  the  formation  of  urea  without  the  liver 
having  anything  to  do  with  it. 

The  second  peculiarity  is  that  we  have  double  the  quantity  of 
kidney  substance  that  we  need.  I  knew  a  man  who  lived  in  good 
health  for  thirteen  years  without  knowing  that  he  had  only  one  kidney 
to  go  by,  the  other  having  been  ruined  by  a  calculus  impacted  in  its 
ureter,  with  the  usual  results  of  complete  destruction  of  the  gland. 
After  thirteen  years  he  had  a  similar  calculus  close  his  remaining  ureter, 
so  that  not  a  drop  of  urine  reached  his  bladder  for  nine  days  until  I 
saw  him,  when  he  told  me  that  he  felt  quite  well.  He  then  had  no 
sign  whatever  of  kidney  trouble,  nor,  indeed,  of  any  other  trouble. 
I  could  note  only  that  his  pupils  were  symmetrically  contracted,  and 
that  he  had  a  few  muscular  twitchings.  I  told  his  physician  that  the 
man  would  soon  die  unless  he  would  cut  down  on  the  impaction  and 
free  the  ureter  of  it.  This  he  declined  to  do,  though  he  was  a  hospital 
surgeon,  unless  the  patient  showed  signs  of  uremia.  I  answered  that 
the  man  would  die  without  any  signs  of  uremia,  and  so  he  did,  appa- 

420 


ACUTE   NEPHRITIS  ,421 

renti}'  from  pure  asthenia  and  conscious  to  the  last.  These  and 
other  Hke  facts,  also,  show  how  much  we  have  yet  to  learn  about  the 
kidneys. 

Causes. — We  prefer,  therefore,  to  take  up  the  ordinary  affections 
of  the  kidney  seriatum,  and  begin  with  acute  nephritis.  A  common 
cause  of  this  affection  thoroughly  illustrates  the  mechanism  of  Catching 
Cold,  which  is  the  subject  of  our  first  chapter.  The  vasomotor  nerves, 
distributed  through  the  skin  over  the  kidneys,  both  anteriorly  and 
posteriorly,  show  in  their  action  how  sensitive  the  kidneys  are  to  the 
surface  impression  of  cold  as  well  as  of  other  surface  irritations.  Years 
ago  I  read  a  paper  by  Brown-Sequard,  in  which  he  stated  that  he  roused 
a  patient  from  uremic  coma  by  the  light  application,  over  kidneys 
before  and  behind,  of  spoons  dipped  in  boiling  water.  I  soon  had  a 
test  which  proved  the  efficacy  of  this  measure.  A  boy  twelve  years 
of  age  had  acute  suppression  of  urine  following  an  attack  of  scarlet 
fever.  Every  measure  tried  to  restore  the  secretion  had  failed,  until 
after  eight  days  of  total  suppression  he  had  a  convulsion.  A  physician, 
who  was  then  called  in,  pronounced  the  boy  dead,  for  he  did  not  re- 
spond to  brushing  of  his  eyes,  nor  could  he  be  made  to  gag  by  introduc- 
ing the  finger  into  his  fauces.  When  I  came  in  I  ordered  several  table- 
spoons to  be  dipped  in  scalding  water,  and  repeated  these  touches  as 
Brown-Sequard  had  advised.  After  ten  such  appHcations  the  boy 
opened  his  eyes  for  a  moment.  I  then  gave  a  high  enema  of  normal 
saline,  whereupon,  as  it  acted,  he  passed  a  small  quantity  of  bloody 
urine.     I  afterward  received  the  wedding  card  of  this  patient. 

A  tjApical  form  of  acute  nephritis  occurs,  as  we  have  already  de- 
scribed, as  a  comparatively  late  complication  of  scarlet  fever.  This 
does  not  develop  durmg  the  height  of  the  fever,  but  usually  from  two 
to  four  weeks  after  its  onset,  and  it  occurs  without  any  reference  to  the 
severity  of  the  primary  attack,  for  it  may  follow  upon  such  a  mild 
onset  that  the  child  can  scarcely  be  kept  from  its  play.  In  my  ex- 
perience, the  earliest  symptom  of  its  approach  is  a  diminution  in  the 
amount  of  urine  passed,  and  I  have  noticed  this  to  be  unaccompanied 
by  any  other  symptom,  the  urine  being  free  from  albumin  and  quite 
clear  or  colorless.  Very  soon  after  this  edema  shows  itself  in  the  face, 
and  the  first  untoward  symptom  may  be  an  attack  of  vomiting. 
The  urine  then  progressively  diminishes  and  often  is  bloody,  until, 
finally,  total  suppression  may  occur  accompanied  by  fever.  The 
dropsy  may  then  become  quite  general,  but  there  are  cases  in  which 
there  is  no  dropsical  period;  the  pulse,  however,  is  of  high  tension  and 
very  small,  as  it  has  been  all  along  in  this  fever.     At  autopsy  the  organ 


422  CLINICAL   MEDICINE 

is  found  much  enlarged,  though  its  capsule  remains  non-adherent.  On 
cutting  into  it  the  kidney  is  found  surcharged  with  blood,  and,  on 
further  examination,  the  glomeruh  are  completely  congested,  the  cells 
lining  Bowman's  capsule  being  greatly  swollen,  while  the  Hning  cells' 
of  the  tubules  are  similarly  affected,  the  tubes  being  stuffed  with 
detached  epithelium  and  blood-corpuscles.  Throughout  the  organ 
also  an  abundant  infiltration  of  leukocytes  and  of  small  cells  shows 
the  intensity  of  the  inflammatory  process.  The  interstitial  tissue  is 
likewise  affected  and  the  pyramids  stand  out  red,  their  tubes  filled 
with  blood. 

When  recovery  takes  place  the  first  favorable  symptom  is  an 
increase  in  the  secretion  of  urine,  from  which  the  blood,  and  then  the 
albimiin,  and  later  the  tube-casts,  gradually  disappear.  This  process, 
however,  may  take  some  time,  and,  in  some  instances,  it  is  never  com- 
plete, the  affection  of  the  kidneys  becoming  essentially  chronic  and 
may  last  a  lifetime.  The  practical  point,  therefore,  in  the  treatment 
of  acute  nephritis  is  to  prevent  the  disease  from  becoming  chronic, 
although  the  supervention  of  chronic  disease  upon  acute  nephritis  is 
exceptional. 

As  we  have  already  intimated,  acute  nephritis  may  have  its  origin 
literally  from  the  kidneys  catching  cold.  The  initial  irritation  of  cold 
may  begin  with  the  wetting  of  the  feet,  as  we  have  before  explained, 
and  some  of  the  worst  cases  may  be  traced  to  this  cause.  It  is  not 
necessary,  therefore,  that  acute  nephritis  from  cold  should  always 
begin  by  exposure  of  the  skin  over  the  kidneys,  but,  once  induced, 
acute  nephritis  from  catching  cold  may  differ  but  little  from  that  which 
is  a  sequel  to  scarlet  fever,  the  only  difference  perhaps  being  the  greater 
tendency  of  such  nephritis  to  become  chronic.  Hence,  the  frequency 
of  kidney  disease  in  hospital  patients  who  have  often  been  exposed  to 
sudden  changes  in  the  weather  in  their  various  avocations. 

Treatment. — As  to  the  prophylaxis  of  acute  nephritis  following 
scarlet  fever,  it  is  noteworthy  how  difficult  it  is  to  devise  any  measures 
which  will  prevent  this  compHcation.  Children  who  have  been  most 
sedulously  kept  indoors  seem  to  be  just  as  liable  to  the  attack  as  those 
who  have  had  no  care  taken  of  them. 

We  shall  have  frequent  occasion  to  note  the  advantage  of  careful 
attention  to  the  functions  of  the  skin  in  all  forms  of  disease  of  the 
kidneys.  There  is  an  intimate  association  between  the  skin  and  the 
kidneys,  which  is  known  to  all  persons  by  the  difference  in  the  quan- 
tity of  urine  excreted  during  cold  and  during  hot  weather.  I  have, 
therefore,  been  accustomed  systematically  to  use  oily  inunctions  of  the 


CHRONIC  NEPHRITIS  423 

skin  in  all  kidney  diseases  which  affect  the  general  nutrition.  This 
ancient  practice  of  anointing  the  skin  was  once  universal,  and  there 
can  be  no  doubt  that  its  discontinuance  in  modern  times  has  had  its 
disadvantages. 

As  might  be  supposed,  the  first  indication  in  acute  nephritis  is  to 
restore  and  to  increase  the  secretion  of  urine.  This  is  best  done  by 
persevering  irrigation  of  the  colon  with  hot  normal  saline.  Kemp's 
rectal  irrigator,  with  its  double  flow,  both  in  and  out,  is  the  best  mech- 
anism yet  devised  for  this  purpose.  The  bag  of  the  fountain  syringe, 
filled  with  the  water,  should  be  attached  to  the  irrigator,  and  from  2  to 
4  gallons  of  water,  at  a  temperature  of  115°  F.,  or  even  120°  F.,  should 
be  employed.  We  have  no  means  equal  to  this  for  restoring  the  dimin- 
ished flow  of  urine  from  whatever  cause.  At  the  same  time,  dry  cup- 
ping of  the  kidney  region,  both  anteriorly  and  posteriorly,  should  be 
employed.  In  adults,  if  other  means  fail,  venesection  should  be 
employed.  After  the  skin  also  has  been  well  oiled  a  warm  bath  may 
be  administered  of  from  ten  to  fifteen  minutes.  As  soon  as  the  urinary 
secretion  is  established  hot  drinks  should  be  given  freely,  plain  water 
itself  being  one  of  the  best  diuretics.  I  have  found  also  profuse  sweat- 
ing, produced  by  yV  g^.  of  pilocarpin,  sometimes  very  efficacious,  but 
care  should  be  taken  with  this  agent  if  the  heart  is  weak.  Medicinal 
diuretics  should  be  only  of  one  class,  viz.,  an  infusion  of  digitalis,  and 
from  two  teaspoonfuls  to  a  tablespoonful  once  every  three  hours,  with 
I  gr.  of  calomel  rubbed  up  in  sugar  and  divided  into  six  doses,  one  to 
be  taken  every  fifteen  minutes. 

After  convalescence  has  been  established  iron  should  be  adminis- 
tered, of  which  for  children  the  syrup  of  the  iodid,  in  half-teaspoonful 
doses,  is  the  best  preparation. 

CHRONIC  NEPHRITIS 

No  organs  of  the  body  present  such  a  variety  of  chronic  affections 
as  the  kidneys.  The  same  may  be  said  also  of  the  accompanying 
clinical  symptoms,  or  even  the  want  of  such  symptoms.  Some  persons 
may  pass  years  with  steady  progress  of  the  processes  of  interstitial 
nephritis  without  being  aware  of  the  serious  nature  of  their  disorder, 
until  suddenly,  and  without  warning,  fatal  uremic  symptoms  develop. 

Chronic  diseases  of  the  kidneys  are  commonly  classified  according 
to  the  conditions  in  which  a  kidney  is  found  at  autopsy  We  begin, 
therefore,  with  that  affection  called  the  large  white  kidney. 

Symptoms. — The  synonyms  of  this  affection  are  chronic  parenchy- 
matous nephritis,  chronic  desquamative  and  chronic  tubal  nephritis, 


424  CLINICAL  MEDICINE 

and  chronic  diffuse  nephritis  with  exudation.  These  names  are  sup- 
posedly based  upon  the  changes  in  the  kidney  substance  found  at 
autopsy.  They  do  not,  however,  correctly  describe  the  affection 
itself,  because  in  all  cases  of  supposed  chronic  parenchymatous 
nephritis  there  is  always  found  a  marked  overgrowth  of  the  inter- 
stitial or  connective-tissue  elements,  varying  both  in  degree  and  in 
situation.  In  some  places  the  interstitial  changes  are  marked,  while 
in  others  the  alterations  in  the  parenchyma  of  the  organ  are  the  most 
in  evidence.  The  accompan3dng  chnical  s3anptoms  are  really  more 
characteristic  in  this  disorder  than  the  anatomic  description  would 
indicate.  Those  symptoms  are,  first,  a  copious  discharge  of  albumin  in 
the  urine,  but  still  more  characteristic  is  the  general  anasarca  or  dropsy 
which  in  this  form  is  usually  extreme.  We  have  no  explanation  of  the 
mechanism  of  this  dropsy  any  more  than  in  any  other  condition  of 
edema,  but,  in  general,  its  characteristics  are  these,  that,  instead  of 
cardiac  dropsy,  which  usually  begins  first  in  the  lower  extremities  and 
increases  upward,  renal  dropsy  shows  its  earliest  signs  in  the  face,  and 
notably  in  the  eyelids  and  other  loose  tissues  about  the  face.  It  is  an 
illustration  of  a  variety  of  conditions  in  B right's  disease  that  in  chronic 
interstitial  nephritis  there  is  usually  no  dropsy  whatever  and  scarcely 
more  than  traces  of  albumin  in  the  urine. 

Accompanying  the  dropsy  there  is  a  marked  anemia,  very  evident 
in  the  face,  but  what  is  not  so  evident  at  first  is  the  wasting  of  the 
muscular  tissues.  This  may  be  concealed  by  the  swelling  of  the  body, 
but,  should  the  edema  subside  from  any  cause,  the  general  emaciation 
becomes  very  evident.  The  accompanjdng  anemia  is  best  explained 
by  the  severe  toxemia  destroying  the  blood-corpuscles,  but  it  also 
explains  the  general  weakness  and  prostration  of  the  patients,  so  that 
they  are  wholly  unable  to  stand  or  walk  and  are  obliged  to  take  to  their 
beds. 

Local  troubles  also  develop  in  the  skin,  such  as  erythema  or  even 
cutaneous  eruptions,  often  accompanied  with  intense  itching.  In  some 
cases  even  bullae  may  form,  which  constitute  serious  complications  in 
the  course  of  the  disease.  All  these  are  more  or  less  caused  by  the 
mechanical  interruption  of  the  blood-supply  to  the  skin  by  the  presence 
of  subcutaneous  edema,  and,  therefore,  as  you  shall  see,  are  to  be  early 
treated  by  proper  attention  to  the  devitalized  skin. 

As  we  have  remarked,  the  clinical  accompaniments  of  the  differ- 
ent forms  of  chronic  Bright's  disease  are  much  more  distinctive  than 
the  findings  in  their  morbid  anatomy.  Thus,  clinically,  no  contrasts 
should  be  greater  than  between  what  is  called  chronic  parenchjrmatous 


CHRONIC   NEPHRITIS  425 

nephritis  and  chronic  interstitial  nephritis.  In  the  first  the  most 
prominent  feature  is  the  dropsy,  which,  beginning  with  swollen  eyelids 
and  puffy  features,  soon  passes  into  a  general  and  often  extreme  ana- 
sarca, till  the  skin  may  burst  from  the  fluid  distention.  Marked 
pallor  from  anemia  is  also  present.  In  interstitial  nephritis  anemia  is 
not  often  recognizable,  nor  is  there  any  dropsy  whatever.  In  paren- 
chymatous nephritis  the  urine  may  at  first  be  scanty  and  of  high 
specific  gravity,  to  become  later  more  abundant,  but  always  there  is 
abundant  quantity  of  albumin  which  no  known  measures  can  diminish. 
In  the  interstitial  form  the  quantity  of  urine  is  abundant,  but  of  low 
specific  gravity,  while  albumin  may  not  be  present  at  all  or  be  only  in 
small  quantities.  The  contrasts  in  the  history  of  the  patients  is  greater 
still.  Those  sick  with  parenchymatous  nephritis  soon  have  to  take 
to  their  beds.  With  interstitial  nephritis  they  may  go  for  many 
months,  quite  unaware  that  anything  is  the  matter  with  them,  and 
continue  to  pursue  their  avocations  just  as  usual,  until  suddenly  an 
explosion,  as  it  were,  of  apoplexy  soon  takes  them  off.  One  symptom 
in  chronic  interstitial  nephritis,  though  occasionally  present  in  the 
terminal  stages  of  other  forms,  is  a  staring  expression  of  the  eyes  caused 
by  immobility  of  the  iris.  The  expression  of  the  eyes  is  due  to  rapid 
changes  in  the  iris,  but  in  all  uremic  states  the  iris  is  well-nigh  immo- 
bile to  emotions,  though  less  so  to  light. 

Besides  these  two  forms  of  chronic  parenchymatous  nephritis  and 
of  the  interstitial  nephritis,  ending  in  the  shrunken  red  and  granular 
kidney,  there  is  a  form,  described  particularly  by  Rose  Bradford,  of 
the  small  contracted  white  kidney. 

Here,  again,  the  clinical  facts  are  the  most  distinctive  of  this  par- 
ticular affection,  because,  instead  of  occurring  as  the  red  contracted 
kidney  does,  chiefly  after  middle  age,  the  white  contracted  kidney 
occurs  among  adolescents  or  in  young  adults.  Unlike  the  case  with 
the  large  white  kidney,  dropsy  may  not  be  present  at  any  time  in  the 
course  of  the  disease.  Albumin  is  also  not  so  abundant  in  the  urine. 
Meanwhile  the  cardiovascular  changes,  though  present,  are  not  so 
pronounced  as  in  the  contracted  red  kidney.  It  cannot  be  said  that 
the  small  contracted  white  kidney  is  a  sequel  to  the  large  kidney,  be- 
cause the  clinical  accompaniments  are  quite  different,  besides  the  fea- 
tures which  we  have  mentioned  of  their  general  occurrence  in  young 
adults.  Anatomically,  a  small  white  kidney  presents  a  great  shrinkage 
in  the  cortical  layer  and  a  wasting  or  disappearance  of  the  tubular 
structures.  On  stripping  the  capsule  the  organ  seems  quite  granular, 
resembling  the  contracted  red  kidney,  except  in  color.     The  usual 


426  CLINICAL  MEDICINE 

clinical  cause  is  progressive  general  ill  health,  with  marked  anemia,  loss 
of  appetite,  various  digestive  disorders,  and  finally  death,  with  uremic 
symptoms,  though  convulsions  are  much  less  common  than  in  the 
course  of  chronic  red  contracted  kidney. 

Treatment  of  Parenchymatous  Nephritis. — This  affection,  on  the 
whole,  is  the  most  difficult  to  treat  of  all  renal  derangements,  owing 
to  the  obstinacy  of  the  dropsy  and  the  liabiHty  to  serious  complica- 
tions. Often  the  first  of  these  developments  in  the  alimentary  canal, 
such  as  vomiting,  may  of  itself  cause  the  death  of  the  patient.  At 
first  drop  doses  of  Fowler's  solution  of  arsenic  may  be  given  every  fif- 
teen minutes  until  six  doses  have  been  taken,  when  it  should  be  in- 
termitted. The  next  measure  to  deal  with  the  vomiting  is  by  a 
purge  of  5  gr.  of  calomel  and  35  gr.  of  compound  jalap  powder.  As 
soon  as  the  bowel  has  been  evacuated  the  patient  should  take  |  oz. 
of  equal  parts  of  milk  and  lime-water,  or,  if  this  disagrees,  simple 
barley-water.  Occasionally  drop  doses  of  the  tincture  of  ipecac  may 
be  taken  instead  of  Fowler's  solution.  It  is  not  uncommon,  however, 
for  diarrhea  to  occur  along  with,  or  shortly  after,  the  vomiting.  In 
some  cases  the  diarrhea  is  due  to  a  diphtheric  inflammation  of  the 
colon,  in  which  membranous  exudations  may  be  discharged  by  the 
rectum.  When  this  occurs  I  know  of  no  remedy  better  than  the  tur- 
pentine and  nitrate  of  silver  pill,  recommended  in  the  treatment  of 
hemorrhage  of  typhoid  fever.  It  is  also  in  these  cases  that  mutton 
suet,  tied  up  in  a  rag  and  boiled  in  milk,  will  be  beneficial,  as  it  is  in 
chronic  ulceration  of  the  intestine. 

The  chief  indication,  however,  is  to  relieve  the  kidneys  by  action 
of  the  skin.  We  should  here  explain  that  perspiration  is  interfered  with 
more  effectively  by  subcutaneous  edema  than  by  anything  else  which 
can  happen.  This  is  because  the  edema  mechanically  closes  the  sweat 
ducts  of  the  skin,  as  these  ducts  always  open  on  the  surface,  not  di- 
rectly, but  obliquely,  and  hence  the  subcutaneous  fluid,  acting  directly 
from  within,  effectually  closes  them.  I,  therefore,  always  recommend 
that  the  skin  should  be  thoroughly  oiled,  along  with  active  friction, 
before  any  agent  for  diaphoresis  should  be  used,  because  the  epithelial 
layers  of  the  skin  are,  by  the  oiHng,  mechanically  separated,  and  thus 
reHeve  the  subcutaneous  pressure  of  the  fluid.  These  patients  should 
always  wear  flannels  both  summer  and  winter,  and  at  night  sleep  in 
canton  flannel,  while  those  who  can  afford  it  should  spend  the  winter 
months  in  a  warm  climate.  The  diet  also  should  be  carefully  regulated; 
fruits  and  vegetables  being  generally  employed,  with  certain  ex- 
ceptions to  be  noted.     Among  the  fruits,  grapes  are  justly  celebrated, 


CHRONIC  INTERSTITIAL   NEPHRITIS  427 

but  they  must  be  the  grapes  of  a  warm  dimate,  and  not  the  Concord 
American  grapes,  which  have  a  tough,  acid  pulp  about  the  seed  absent 
in  California  and  Malaga  grapes.  Onions,  particularly  Bermuda 
onions,  are  an  excellent  article  of  food.  Apple-sauce  is  the  only  form 
in  which  apples  should  be  taken.  Beans,  on  the  other  hand,  especially 
Boston  baked  beans,  and  among  the  cereals,  oatmeal,  should  be  for- 
bidden, while  fish  and  poultry  may  be  taken  in  moderation.  Boiled  fish, 
however,  and  the  oily  kinds,  like  salmon,  are  indigestible.  Fermented 
milk  in  its  varied  preparations  should  be  the  ideal  food,  if  it  were  not 
that,  in  severe  cases  of  dropsy,  it  is  sometimes  necessary  to  limit  the 
intake  of  all  fluids.  Coffee  and  tea  in  moderate  quantities  are  allow- 
able.    In  some  cases  salt  has  to  be  left  out. 

The  remaining  affections  of  the  lower  genito-urinary  tract,  such  as 
affections  of  the  prostate  and  of  the  urethra,  are  so  commonly  surgical 
in  their  nature  that  they  do  not  properly  come  within  the  scope  of 
this  work.  I  would  only  allude  to  the  fact,  that  in  elderly  persons  the 
enlarged  prostate  is  covered  in  some  cases  with  dilated  veins,  from 
which  hemorrhage  frequently  occurs.  Usually  this  hemorrhage  is 
very  moderate,  but  enough  to  attract  the  notice  of  the  patient  and 
lead  to  his  seeking  advice  about  it.  When  moderate  it  should  simply 
be  left  alone,  because  it  causes  no  inconvenience.  One  gentleman, 
however,  came  into  my  office  with  his  urethra  full  to  the  meatus  with 
coagulated  blood.  This  bleeding  recurred  with  him  at  intervals  of 
several  months,  until  finally  he  was  cured  by  excision  of  the  prostate. 
It  should  be  remarked  that  every  outlet  from  the  body  should  invariaby 
be  free,  because  even  its  partial  occlusion  leads  to  serious  results. 
This  apphes  as  much  to  the  air-tubes  as  to  the  outlet  of  secretions.  A 
small  constriction  in  the  course  of  a  main  bronchus,  whatever  its  cause, 
leads  to  serious  affections  of  respiration ;  so  polypi  in  the  nose  are  often 
the  causes  of  asthma.  One  of  the  most  singular  illustrations  consists 
of  a  too  small  orifice  to  the  prepuce  in  young  boys.  I  have  repeatedly 
found  that  this  obstruction  reacts  upon  the  spinal  cord,  leading  to  dis- 
turbances which  require  circumcision.  Circumcision,  indeed,  is  a 
hygienic  measure  which  should  be  universally  adopted.  But,  on  the 
same  principle,  no  person  who  has  a  stricture  of  the  urethra  is  a  healthy 
man,  and  at  any  time  this  may  give  rise  to  complications  whose  nature 
may  be  extremely  serious. 

Chronic  Interstitial  Nephritis 
One   feature   in   the  pathology   of   chronic   interstitial   nephritis 
which  separates  it  from  all  other  affections  of    the  kidneys  is  the 


428  CLINICAL  MEDICINE 

concomitant  change  in  the  whole  arterial  system.  The  arteries  are 
everywhere  thickened  by  a  process  which  may  finally  obHterate  entire 
areas  of  arterioles.  It  is  often  difficult  to  decide  whether  this  arterial 
change  does  or  does  not  precede  the  sclerotic  changes  in  the  kidneys 
themselves,  the  most  probable  view  being  that  both  these  alterations 
are  simultaneous  and  due  to  the  same  general  cause. 

The  arterial  changes  are  everywhere  observable.  The  radial  artery, 
for  example,  is  easily  palpable  in  its  bed  as  a  more  or  less  hard  cord, 
which  may  be  uneven  or  bead-like  if  atheromatous  changes  in  its  walls 
have  taken  place.  Meantime  the  effects  of  obstruction  in  the  blood- 
flow  is  readily  perceptible.  The  pulse  feels  hard  and  incompressible, 
as  water  flowing  through  a  hose  would  resist  pressure  if  its  stop-cock 
were  partly  turned.  One  result  of  this  difficulty  in  the  circulation 
should  be  early  recognized  in  the  enlargement  of  the  left  chamber  of 
the  heart,  both  downward  and  to  the  left.  The  most  easily  noted 
changes,  however,  are  in  the  circulation  of  the  skin.  Thus,  that  of  the 
abdomen  is  preternaturally  white,  and  is  not  readily  reddened  by  draw- 
ing the  nail  over  it. 

The  radial  artery,  however,  may  be  palpable  and  the  pulse  feel 
incompressible,  without  any  thickening  of  the  arterial  wall.  This 
may  be  recognized  by  two  fingers  compressing  the  radial  above  while 
the  index-finger  is  left  to  feel  the  emptied  artery  beyond  the  point  of 
compression.  If  the  arterial  wall  is  itself  thickened  this  is  then  felt 
much  as  before,  but,  if  the  vessel  be  only  overfilled,  the  part  is  then 
simply  collapsed. 

This  observation  is  important,  because  it  brings  in  a  new  element 
not  heretofore  alluded  to. 

Next  to  the  heart  itself  the  arteries  constitute  the  most  living 
portion  of  the  circulatory  apparatus,  because  they  are  richly  supplied 
with  their  vasomotor  nerves,  which  both  contract  and  dilate  these 
vessels.  The  whole  arterial  system,  therefore,  may  be  overfull,  on 
account  of  general  vasomotor  contraction,  and,  therefore,  not  due  to 
organic  thickening  of  the  arterial  walls.  Undoubtedly,  this  condition 
may  exist  for  a  long  time  before  resultant  organic  changes  develop 
in  the  walls  of  the  vessels.  It  is  at  this  time,  therefore,  that  measures 
should  be  adopted  to  relieve  the  vessels  from  strain  before  structural 
changes  in  the  arteries  have  occurred.  To  this  condition  the  term 
"angiospasm"  has  been  given,  but,  clinically,  it  is  important  to  note 
that  angiospasm  may  be  very  local  and  not  general,  and  there  can 
be  no  question  that  many  cases  of  rupture  of  a  diseased  artery,  such 
as  in  apoplexy,  may  be  caused  by  local  angiospasm  of  the  cerebral 


CHRONIC   INTERSTITIAL   NEPHRITIS  429 

arteries.  We  often  meet  with  illustrations  of  local  angiospasm  causing 
repeated  attacks  with  cerebral  symptoms  which  may  be  explained  only 
in  this  way.  Thus,  I  have  known  of  patients  having  as  many  as 
ten  to  thirty  attacks  of  true  but  purely  local  apoplexies  in  the  cere- 
bral hemispheres. 

Here,  as  elsewhere,  prophylaxis  is  so  important,  by  the  employ- 
ment of  those  remedies  which  are  true  vasodilators,  of  which,  as  we 
have  remarked  before,  aconite  and  veratrum  viride  are  the  most 
efficacious  agents.  Even  if  sclerotic  changes  have  already  occurred 
in  the  blood-vessels,  the  prevention  of  angiospasm  is  of  great 
practical  importance.  It  is  not  improbable  that  the  prolonged  history 
of  an  active  business  hfe,  in  persons  with  chronic  sclerotic  thickening 
of  the  arteries  and  similar  changes  in  the  kidneys,  is  to  be  explained 
by  the  absence  in  them  of  attacks  of  angiospasm,  until  the  slow  ac- 
cumulations in  the  blood  of  uremic  poisons,  like  other  blood-poisons, 
suddenly  explode  with  fatal  symptoms. 

One  very  common  accompaniment  of  chronic  interstitial  nephritis 
is  polyuria.  I  have  had  such  cases  consult  me  for  this  symptom  alone 
because  they  had  to  rise  so  often  at  night  to  pass  water.  In  fact, 
this  may  be  the  earliest  symptom  of  the  onset  of  the  disease  in  the 
kidneys  when  it  cannot  otherwise  be  accounted  for  by  enlargement  of 
the  prostate. 

Gouty  Nephritis. — Chronic  interstitial  nephritis  occurs  in  many 
cases  of  gout,  so  that  authors,  especially  EngKsh,  speak  of  gouty  kid- 
neys as  such.  We  should  not  expect  the  kidneys  to  be  always  affected 
in  gouty  diseases,  because  many  cases  may  suffer  from  arthritic  gout 
for  many  years  and  yet  never  be  affected  with  gouty  kidney.  Never- 
theless, the  two  affections  do  occur  so  often  that  it  is  proper  to  speak 
of  gouty  nephritis  as  a  distinct  affection,  characterized  by  deposits  of 
acicular  crystals  in  the  kidneys,  especially  in  the  pyramids,  which  in 
some  instances  appear  to  be  encrusted  by  them.  The  treatment  of 
these  cases,  however,  does  not  differ  from  that  already  detailed,  except 
that  such  patients  should  be  freely  dosed  with  the  citrate  of  potash,  as 
hereinafter  prescribed,  for  the  treatment  of  uric-acid  gravel. 

Treatment. — No  kidney  disease  calls  for  such  sedulous  attention  in 
the  way  of  treatment  as  interstitial  nephritis.  By  proper  therapeutic 
measures  many  a  useful  Hfe  may  be  prolonged  for  years  by  observing 
dietetic  rules  and  by  persevering  in  the  use  of  medicinal  remedies. 

In  the  first  place,  the  damaged  kidneys  should  be  relieved  as  far 
as  possible  in  the  work  which  they  have  to  do.  For  this  purpose  all 
red  meats  should  be  avoided,  as  it  is  by  such  articles  of  diet  that 


43©  CLINICAL   MEDICINE 

damaged  kidneys  are  called  upon  to  do  the  most  work.  As  nitrog- 
enous elements  in  our  food  are  absolutely  necessary,  we  should  choose 
the  least  exacting  of  such  articles;  on  that  account  preparations  of 
fermented  milks  are  the  best  adapted,  both  for  nutrition  and  for 
prevention.  Diseases  of  the  kidneys,  in  fact,  are  rare  among  those 
races  who  habitually  use  fermented  milk,  such  as  the  people  of  western 
Asia  and  the  pastoral  Tartar  and  Bedouin  tribes. 

On  the  other  hand,  most  cereals,  with  the  exception  of  oatmeal 
and  all  succulent  vegetables,  can  be  taken  freely.  Such  prepara- 
tions as  baked  beans  are  not  easily  disposed  of  by  the  intestines,  while 
string  beans  are  allowable. 

I  had  a  patient  so  far  advanced  in  this  complaint  that  she  had  al- 
buminuric retinitis,  with  occasional  bright  scotoma,  until  she  could  not 
see  clearly  across  the  room.  I  had  her  rubbed  all  over  the  body  twice 
a  day  with  cocoanut  oil,  and  interdicted  the  use  of  indigestible  vege- 
tables, Hke  beans,  until  albuminuric  casts  disappeared  from  the  urine. 
One  day,  however,  as  she  had  from  childhood  been  very  fond  of  baked 
beans,  she  partook  of  them  at  noon.  That  night  she  was  taken  with 
severe  pains  in  the  bowels,  and  the  next  morning  showed  a  heavy 
precipitate  of  albumin  in  the  urine,  which  did  not  disappear  for  three 
weeks.  This  patient  lived  for  more  than  twenty-five  years  afterward 
in  good  health.  I  mention  this  case  particularly  to  enjoin  that  the 
utmost  care  in  the  treatment  of  kidney  disease  should  be  taken  in  the 
management  of  the  intestinal  canal.  We  have  already  alluded  to  this 
subject  in  our  article  on  Infections  by  the  Bacillus  Coli,  and  I  have 
no  doubt  that  a  large  proportion  of  all  cases  of  chronic  interstitial 
nephritis  are  induced  and  kept  up  by  disorders  of  intestinal  digestion. 
For  the  same  reason,  asparagus  should  be  avoided,  because  all  persons 
will  show  a  quantity  of  crystals  of  oxalate  of  lime  in  the  urine  first 
passed  after  taking  asparagus. 

In  all  cases  of  chronic  interstitial  nephritis,  lo-drop  doses  of  the 
tincture  of  aconite  of  the  Pharmocopeia  of  1890,  four  times  a  day, 
should  be  persevered  in  continuously.  I  have  had  a  number  of  cases 
who  immediately  felt  the  loss  of  this  valuable  vasodilator  whenever 
they  omitted  their  aconite  doses. 

Corrosive  sublimate,  in  doses  of  -j^  gr.  three  times  a  day,  should  be 
taken  systematically  for  ten  days  or  two  weeks,  and  then  intermitted 
for  the  same  period  and  then  resumed.  I  have  repeatedly  known  the 
watery  urine  of  this  disease  to  assume  a  natural  color  while  using 
this  drug.  When  it  is  intermitted,  a  dose  of  5  gr.  of  sodium  iodid 
should  be  taken  instead  three  times  a  day. 


ARTERIORENAL    SCLEROSIS  43 1 

ARTERIORENAL  SCLEROSIS 

Sclerosis  of  the  arteries  and  wasting  of  the  kidney  substance  con- 
secutive to  chronic  interstitial  nephritis  are  so  frequently  associated 
together  that  it  may  become  difficult  to  decide  which  of  these  proc- 
esses came  first. 

Clinically,  it  sometimes  seems  as  if  the  arterial  disease  was  the  true 
antecedent.  This  is  very  different  from  the  same  procedure  in  a 
chronic  febrile  complaint,  Hke  tuberculosis,  and  it  indicates  that  whole 
areas  of  arterioles  have  become  obliterated.  Examination  of  the 
larger  arteries,  such  as  the  temporal  and  radial,  shows  them  to  be 
thickened  and  often  tortuous  in  their  course.  The  pulse  also  is  hard 
or  not  easily  compressible,  and  the  heart  is  hypertrophied  with  accen- 
tuation of  the  second  sound  at  the  origin  of  the  aorta. 

Coincident  with  this  widespread  vascular  disease  the  kidneys 
develop  symptoms  which  are  highly  characteristic,  both  negatively 
and  positively.  The  valuable  danger-signal  of  pain  is  absent.  It  is 
surprising  how  far  the  kidneys  may  become  disorganized  and  wasted 
without  the  patient  being  aware  of  it  until  it  is  too  late  to  attempt  to 
do  anything  for  him.  All  that  he  has  noticed  is  that  he  is  passing  more 
water  than  usual,  nor  is  examination  of  the  urine  necessarily  decisive. 
I  had  a  patient  whose  urine  was  repeatedly  tested  at  the  Harvard 
Laboratory  when  she  went  to  her  country  place  near  Boston,  and  it  was 
uniformly  reported  that  there  were  no  traces  of  albumin  nor  even  of 
casts.  She  had  been  a  patient  of  mine  for  years,  during  which  I  gave 
an  unfavorable  prognosis,  because  the  elimination  of  urea  was  per- 
sistently low.  At  last  she  suddenly  became  uremic  and  died.  Mean- 
time all  her  arteries  which  were  palpable  appeared  to  be  normal  and 
net  thickened,  and  the  heart  was  not  at  all  hypertrophied.  In 
this  case,  therefore,  the  disease  began  in  the  parenchyma  of  the  kid- 
neys and  did  not  involve  the  general  arterial  system.  This  case  shows 
that  it  is  not  enough  in  urine  examination  to  determine  whether  it 
contains  abnormal  ingredients,  but  also  whether  its  normal  constitu- 
ents are  present  in  their  proper  proportions. 

We  know  that  in  cases  of  obstructive  suppression,  when  a  calculus 
is  impacted  in  the  ureter  which  leads  from  the  one  remaining 
kidney  after  the  other  kidney  has  been  destroyed,  that  death  follows 
without  a  S3anptom  of  uremia,  such  as  headache,  vomiting,  or  convul- 
sions, the  patient  dying  instead  with  symptoms  of  simple  asthenia, 
the  mind  being  unaffected  to  the  last. 

We  may  say,  therefore,  that  uremia  is  not  at  all  svnonymous  with 


432  CLINICAL  MEDICINE 

the  retention  of  urea.     Other  changes  have  to  follow  before  suspension 
of  the  elimination  of  urea  will  cause  what  we  call  uremia. 

Treatment. — In  some  cases,  in  which  we  do  not  doubt  that  sclerosis 
or  shrinkage  of  the  kidney  is  present,  we  may  yet  be  uncertain  whether 
enough  kidney  substance  may  not  still  be  left  unaffected,  so  that  life 
may  be  prolonged  or  even  preserved  if  only  we  could  get  those  parts 
of  the  kidney  to  perform  their  functions.  This  is  because  everyone 
has  much  more  kidney  substance  than  he  uses  or  needs,  because  any- 
one can  live  with  only  one  kidney.  It  has  long  been  known  that  vaso- 
dilators, like  amyl  nitrite  and  nitroglycerin  will  temporarily  improve 
the  symptoms  of  these  patients,  but  the  drawback  is  that  the  vaso- 
dilator action  of  the  nitrites  is  very  transient,  as  a  rule  not  lasting 
half  an  hour,  if  so  long.  What  we  need  is  both  a  more  powerful  and  a 
more  continuous  vasodilator  than  they.  Our  present  object  is  to  show 
that  we  possess  in  aconite,  and  to  a  lesser  degree  in  veratrum  viride, 
the  best  vasodilators.  That  this  is  no  theory  is  shown  by  the  fact  that 
the  regular  administration  of  full  doses  of  aconite  is  followed  by  an 
increase  in  the  output  of  urea  by  the  kidneys  equal  to  double  or  treble 
the  amount  excreted  before  the  administration  of  this  drug.  (See  Ar- 
teriosclerosis, page  260,) 

UREMIA 

This  is  a  well-known  morbid  condition,  but  its  actual  etiology  is  quite 
uncertain.  It  surely  is  not  due  to  the  simple  retention  in  the  blood 
of  urea  or  of  its  decomposition  there,  for  I  have  known  of  cases  of 
parenchymatous  nephritis  with  dropsy  in  which  the  excretion  of 
urea  by  the  kidneys  was  but  little  below  the  normal,  and  yet  the 
patients  died  from  pronounced  uremia.  Further,  when  not  a  drop  of 
urine  reaches  the  bladder,  on  account  of  complete  stoppage  by  calcu- 
lus of  the  only  remaining  ureter,  the  patient  dies  at  periods  ranging 
from  seven  to  twelve  days  of  total  suppression,  with  symptoms  only  of 
pure  asthenia,  without  a  single  one  of  the  characteristic  signs  of 
uremia.  Moreover,  a  patient  with  chronic  interstitial  nephritis  may  go 
for  months  in  apparently  good  health  and  then  suddenly  develop  all 
the  symptoms  of  uremia  and  soon  die  in  them.  These  facts  have 
caused  a  great  number  of  theories  to  be  advanced  to  account  for 
this  serious  condition,  but  none  of  them  afford  a  fully  satisfactory 
solution. 

Symptoms. — Acute  uremia  may  come  on  in  any  form  of  nephritis. 
Its  symptoms  in  some  cases  may  develop  very  gradually,  and  in  others 
suddenly  and  without  warning.     For  convenience,  we  can  divide  these 


UREMIA  433 

symptoms  into  cerebral,  circulatory,  and  gastro-intestinal,  though 
cases  occur  in  which  all  three  forms  rapidly  succeed  one  another. 

Cerebral  Symptoms. — A  group  of  these  take  the  form  of  sudden 
insanity.  Thus,  a  patient  of  mine,  who  a  few  weeks  previously  had 
caught  cold  standing  on  the  wet  ground  in  the  cemetery  at  the  funeral 
of  his  wife,  first  had  an  attack  of  pleurisy  with  effusion,  from  which 
he  so  far  recovered  that  he  returned  to  business,  and  then  one  day  went 
to  his  bank  and  without  reason  upbraided  the  officials  for  refusing  to 
cash  one  of  his  checks.  He  was  then  sent  home,  and  I  was  summoned 
to  see  him.  I  had  great  difi&culty  in  persuading  him  to  go  to  bed,  but, 
after  doing  so,  he  refused  to  get  out  of  bed  again  on  any  pretext,  pass- 
ing his  motions  in  bed,  and  maintaining  that  he  had  gone  there  by  my 
orders  and  there  he  was  going  to  stay.  Meantime  I  examined  his 
urine,  and  found  it  highly  albuminous  with  casts.  He  gradually  re- 
covered from  this  condition,  so  that  he  went  about,  but  was  very  taci- 
turn and  became  markedly  pale.  He  continued  in  this  condition  until 
he  went  South,  his  urine  still  remaining  albuminous.  After  some 
weeks  he  returned,  when  his  mind  suddenly  cleared  up  on  develop- 
ment of  bilateral  pleurisy  with  effusion.  In  time  he  recovered  com- 
pletely from  this,  so  that  he  was  able  to  return  to  his  business  as  if 
nothing  had  happened,  and  in  the  course  of  two  years  he  married 
again  and  lived  for  a  number  of  years  afterward  without  any  kidney 
symptoms.  This  case  illustrates  how  varied  the  uremic  conditions 
may  be. 

In  other  cases,  notably  in  chronic  interstitial  nephritis,  melancholia 
may  develop  with  suicidal  tendencies.  These  cases  are  apt  to  have 
high-tension  pulse  and  should  be  treated  accordingly. 

At  other  times  epileptiform  convulsions  set  in  often  without  ante- 
cedent symptoms,  though  usually  with  headache.  The  convulsions 
are  so  much  like  epilepsy  that  even  cases  of  Jacksonian  localized 
convulsions  have  been  reported.  In  some  cases  the  subsequent  coma 
becomes  more  and  more  profound  until  it  ends  in  death.  In  some 
instances  when  a  patient  comes  out  of  a  convulsion  he  is  bfind,  which 
fact  settles  its  uremic  character.  Uremic  amaurosis  ordinarily  passes 
off  within  a  few  hours  or  a  few  days,  and  it  is  remarkable  that  it  is  not 
accompanied  by  changes  in  the  retina.  Tjq^ical  delusional  insanity, 
often  with  ideas  of  persecution,  may  last  for  a  number  of  weeks. 

After  a  convulsion  it  is  not  uncommon  for  various  monoplegias  in 
the  arm  or  leg  to  be  present,  or  even  hemiplegias,  which,  on  account 
of  their  toxic  origin,  leave  no  traces  in  the  brain.  Uremic  dyspnea 
is  very  apt  to  assume  all  the  characters  of  asthma,  and  the  physician 

28 


434  CLINICAL  MEDICINE 

when  called  to  such  a  case  should  be  on  his  guard,  for,  if  the  patient  is 
past  middle  life,  and  has  never  had  attacks  of  asthma  before,  this 
attack  is  very  likely  uremic.  At  other  times  the  breathing  may  be 
hurried  and  then  subside,  to  come  on  again  a  short  time  afterward. 
Another  form  occurs  in  attacks  of  Cheyne-Stokes  respiration,  which 
recurs  at  intervals  for  long  periods  of  time. 

Of  the  circulatory  symptoms  we  may  have  violent  palpitation  of 
the  heart,  during  which  the  pulse  becomes  very  irregular.  Another 
symptom  is  hiccup,  which  may  be  distressing  and  tormenting  to 
the  patient  for  days  and  nights  together.  At  all  times,  when  the 
S5nnptoms  of  uremic  dyspnea  are  present,  the  physician  should  be  on 
the  lookout  for  the  supervention  of  fatal  pulmonary  edema,  or  effusion 
into  the  serous  sacs,  both  in  the  pleura  and  the  pericardium.  It 
should  be  mentioned,  however,  that,  though  the  attacks  may  take 
the  form  of  pericarditis  or  of  pleuritis,  there  is  much  more  effusion  into 
these  serous  sacs  than  pain.  So  often  are  the  attacks  painless  that  they 
may  be  overlooked  altogether. 

The  gastro-intestinal  symptoms  are  also  very  characteristic,  the 
commonest  being  uncontrollable  vomiting,  associated  with  great 
nausea,  the  patients  often  objecting  to  the  very  sight  of  food.  Some- 
times nothing  will  control  the  vomiting,  and  the  patients  apparently 
die  from  it.  Not  uncommonly  the  vomiting  is  accompanied  by  ob- 
stinate diarrhea.  This  diarrhea  may  become  chronic  and  characterized 
by  the  formation  of  extensive  diphtheric  exudations  in  the  colon,  when 
the  patients  may  pass  long  flakes  of  those  exudates.  Both  the  vomit- 
ing and  the  diarrhea  are  accompanied  by  great  general  prostration. 
In  all  these  conditions  of  uremia  a  striking  symptom  is  a  very  staring 
expression  of  the  eyes,  due  to  a  virtual  paralysis  of  the  iris.  In  health 
the  expression  of  the  eyes  is  often  very  striking  in  showing  passing 
conditions  of  emotion,  all  caused  by  rapid  changes  in  the  iris.  So 
accustomed  do  we  become  to  this  ocular  phenomena,  that  we  are  sure 
to  note  the  fixed  condition  in  uremia  from  the  eye  appearing  so  star- 
ing. This  staring  expression  has  of  itself  often  led  me  to  suspect  ure- 
mia when  I  first  have  seen  a  patient  with  it,  for  it  is  not  likely  to  be 
present  in  any  other  condition,  except  in  some  cases  of  chlorosis. 

Treatment. — The  treatment  of  uremia  when  the  diagnosis  is  once 
settled  should  be  the  treatment  of  the  particular  form  of  kidney  disease 
upon  which  it  depends.  Thus,  uremia  developing  in  a  child  with  scar- 
latinal nephritis  differs  materially  from  the  treatment  of  uremia  super- 
vening in  an  adult  with  chronic  interstitial  nephritis. 


NEPHROLITHIASIS    (OXALURIA)  435 

NEPHROLITHIASIS   fOXALURIA) 

While  the  clinical  symptoms  of  gravel  or  of  stone  in  the  kidney  are 
usually  very  distinctive,  there  is  no  subject  in  biochemistry  which  is 
more  often  discussed,  without  satisfactory  explanation,  than  the  va- 
rious disorders  due  to  uric  acid  in  the  blood  or  in  the  urinary  pass- 
ages. This  is  illustrated  in  discussions  upon  the  origin  of  those  so- 
called  purin  bodies  which  are  antecedents  in  the  metabolism  of 
urea  and  of  uric  acid.  It  is  there  often  stated  that  uric  acid  is  a 
less  oxidized  product  than  that  very  soluble  urea,  which  is  the  chief 
final  element  in  us  of  nitrogenous  metabolism.  But,  if  so,  it  is  diffi- 
cult to  account  for  the  fact  that  birds  habitually  excrete  uric  acid  in- 
stead of  urea,  while  birds  take  in  proportionately  more  oxygen  in  their 
breathing  than  we  ever  do. 

In  normal  human  urine  uric  acid  is  always  present,  but  in  a  minute 
fraction,  the  average  proportion  of  uric  acid,  as  compared  to  urea,  being 
I  to  50. 

Uric  acid  is  present  in  excess  in  the  blood  in  all  gouty  conditions, 
where  it  combines  with  soda  to  form  the  insoluble  biurate.  It  requires, 
however,  some  other  element  to  be  present  to  cause  uric  acid  to  be 
formed  as  an  insoluble  precipitate  in  the  kidney  or  urinary  passages 
so  as  to  occasion  attacks  of  gravel  or  of  kidney  coHc.  These  calcuU, 
in  fact,  are  composed  chiefly  of  pure  uric  acid,  and  the  conditions  of 
their  formation  are  clinically  well  marked;  one  of  them  being  that 
the  urine  itself  should  be  highly  acid.  Taking  food,  particularly 
much  vegetable  food,  causes  at  first  alkalinity  of  the  urine,  but,  as 
time  elapses,  the  urine  begins  to  be  acid,  and  in  four  or  five  hours 
afterward  still  more  so.  It  is  the  rule,  therefore,  that  uric  acid  is 
precipitated  by  very  acid  urine,  so  that  the  first  attacks  of  gravel  or 
of  kidney  colic  usually  come  on  after  midnight.  Commonly,  when 
these  attacks  are  habitual,  the  patient  complains  of  dull  aching  in  the 
back,  which  may  continue  for  a  long  while,  until  a  paroxysm  of  pain 
sets  in  with  great  severity;  the  pain  radiating  down  the  groin,  usually 
on  one  side,  on  the  inside  of  the  thigh,  and  in  the  testicle  on  that  side. 

If  a  calculus  is  formed  in  the  kidney,  and  becomes  dislodged  so 
as  to  enter  the  ureter,  the  pain  there  presents  all  the- characters  of  a 
stretching  pain  which  we  have  described,  accompanied  by  nausea 
or  vomiting  with  a  sense  of  fainting,  and  not  uncommonly  with  a  cold 
perspiration,  which  continues  until  the  calculus  has  dropped  into  the 
bladder.  Sometimes  these  renal  calculi  are  so  large  that  they  remain 
in  the  kidney  for  years,  producing  constant  backache,  accompanied 
frequently  by  hematuria.     In  such  cases  the  diagnosis  may  become 


436  CLINICAL  MEDICINE 

settled  by  an  x-ray  picture,  the  taking  of  which  has  recently  been  so 
much  improved  that  this  procedure  should  never  be  omitted  in  ob- 
scure cases.  If,  instead  of  one  large  calculus,  the  case  is  one  of 
gravel,  minute  crystals  may  then  be  found  in  the  urine  which  are 
visible  to  the  naked  eye.  Not  uncommonly  a  calculus  grows  in 
the  bladder  by  accretion  of  such  crystals  imtil  a  real  stone  is  formed, 
which  causes  cystitis  and  a  frequent  desire  to  pass  water,  and  severe 
pain  at  the  neck  of  the  bladder  with  pain  referred  to  the  head  of  the 
penis. 

Unlike  so-called  gall-stones,  calculi  in  the  bladder  are  real  stones 
and  cannot  be  dissolved,  and  hence  can  be  gotten  rid  of  only  by  opera- 
tions. A  great  deal,  however,  can  be  accomplished  in  the  way  of 
prophylaxis.  Persons  who  are  subject  to  attacks  of  gravel  should 
take  I  dram  of  citrate  of  potash  an  hour  after  each  meal  and  a  full 
dram  on  going  to  bed.  For  the  resulting  inflammatory  state  of  the 
urinary  passages  a  prescription  of  the  fluidextract  of  buchu  with 
liquor  potassium  (see  Pyelitis)  will  be  of  great  service,  while  the  diet 
should  be  regulated  by  abstaining  from  the  red  meats  and  from  sweet- 
breads, as  well  as  from  fermented  liquors  of  all  kinds,  whether  wines  or 
beers.  These  patients  should  partake  freely  of  water;  if  not,  a  mild 
alkaHne,  like  Vichy. 

Some  calculi  which  cause  the  greatest  pain  in  passing  are  composed 
of  oxalate  of  lime,  which  form  such  jagged  concretions  that  the  edges 
irritate  the  urinary  passages.  Such  patients  should  carefully  avoid 
taking  asparagus,  and  should  resort  to  a  mercurial  purge  once  or  twice 
a  week. 

We  may  have  phosphatic  calcuH  form  in  the  bladder  from  the  op- 
posite condition  of  alkaline  urine,  giving  rise  to  phosphatic  deposits, 
already  referred  to  under  the  heading  of  Phosphaturia.  These  calculi 
are  formed  usually  of  calcium  phosphate  and  ammonium  magnesium 
phosphate.  These  may  grow  into  the  largest  calculi  that  are  found  in 
the  bladder,  having  frequently  begun  with  a  nucleus  of  uric  acid,  and 
which  can  be  got  rid  of  only  by  operation. 

Other  conditions  of  the  urine  are  also  common.  Stones  composed 
of  uric  acid  and  urate  are  common  at  both  periods  of  life,  among  chil- 
dren and  persons  above  fifty.  It  is  difficult  to  account  for  their  fre- 
quency in  children,  unless  it  be  from  a  greater  tendency  to  a  formation 
of  high  acid  urine  then,  which  diminishes  afterward  under  a  mixed 
diet.  The  calculi  composed  of  an  oxalate  of  lime  are  often  dark  in 
color  and  are  very  hard.  Bacteria  are  sometimes  found  as  if  they 
were  a  nucleus  around  which  the  uric-acid  crystals  are  collected.     This 


CYSTITIS 


437 


would  be  analogous  to  the  formation  of  many  gall-stones,  of  which 
masses  of  the  Bacillus  coli  are  so  often  the  beginning.  When  calculi 
are  numerous  in  the  pelvis  of  the  kidney  they  not  uncommonly  produce 
pyuria  as  well  as  hematuria. 

Uric  acid  occurs  in  the  urine  in  combination  with  ammonium  and 
sodium,  forming  the  acid  urates.  These  urates  may  be  held  in  solu- 
tion while  the  urine  is  warm,  but  are  deposited  in  the  vessel  as  soon  as 
it  cools,  forming  what  is  called  the  brick-dust  deposit,  in  which  it  is 
important  to  remember  that  the  uric  acid  itself  may  not  be  in  excess, 
but  only  its  salts.  As  a  rule,  however,  the  habitual  occurrence  of  brick- 
dust  sediment  should  lead  to  the  administration  of  mild  alkalis,  hke 
the  citrate  of  potash,  20  or  30  gr.,  three  times  a  day.  It  is  not  un- 
common in  such  cases  to  have  attacks  of  lumbago  supervene,  which 
should  always  be  treated  by  administrations  of  mercurial  laxatives, 
such  as  a  5-gr.  blue  pill,  to  be  followed  by  a  mineral  water,  such  as  the 
Pluto  water,  repeated  every  other  night  in  obstinate  cases. 

As  uric-acid  concretions  are  the  commonest  causes  of  urinary  gravel 
it  is  well  to  note  that,  although  common  in  gouty  persons,  many 
patients  with  pronounced  gout  are  never  troubled  with  uric-acid  con- 
cretions of  calculi  in  either  kidney  or  bladder.  There  must,  therefore, 
be  some  special  element  or  enzyme  present  in  these  patients  to  render 
them  subject  to  such  disorders. 

CYSTITIS 

Disorders  of  the  urinary  passages  which  remain  for  our  considera- 
tion are  cystitis,  prostatitis,  and  urethritis.  Cystitis  is  an  inflamma- 
tion of  the  mucous  membrane  of  the  urinary  bladder,  and  is  generally 
due  to  the  invasion  of  the  bladder  by  micro-organisms.  Hence,  it 
very  often  follows  catheterization  by  which  various  micro-organisms 
are  introduced.  A  common  cause  is  due  to  the  extension  backward 
of  urethritis  produced  by  gonorrhea.  In  elderly  persons  it  may  be 
caused  by  the  loss  of  tone,  produced  by  overdistention  of  the  blad- 
der following  the  obstruction  by  an  enlarged  prostate,  and  it  also  is 
often  caused  by  the  presence  of  calculi.  The  symptoms  of  acute  cys- 
titis are  pain,  referred  to  the  region  of  the  bladder  in  front,  and  in  some 
cases  to  the  perineum.  Along  with  the  pain  is  a  very  frequent  desire 
to  pass  water,  which  may  interfere  with  the  sleep  of  the  patient.  In 
addition  to  the  causes  enumerated,  the  bladder  is  sometimes  invaded 
by  the  tubercle  bacilH,  which  produce  very  obstinate  disorders  of 
the  organ  and  quite  commonly  hemorrhage.  This  infection  is  fre- 
quently a  result  of  tuberculous  kidney.     The  urine  contains  a  large 


438  CLINICAL   MEDICINE 

amount  of  pus,  and,  in  chronic  cases,  this  may  produce  a  ropy  sediment, 
with  accompanying  ammoniacal  decomposition  of  the  urine  and  an 
abundant  formation  of  crystals  of  triple  phosphate.  When  a  cystitis 
is  caused  by  one  or  more  calculi  in  the  bladder  the  pain  is  much  aggra- 
vated at  the  end  of  the  act  of  micturition.  The  pain  may  then  be 
very  characteristically  referred  to  the  head  of  the  penis. 

Treatment. — In  all  cases  of  chronic  cystitis  no  measure  is  so  effectual 
as  washing  out  the  bladder.  This  should  be  done  by  first  injecting 
not  more  than  an  ounce  at  a  time  of  the  saturated  solution  of  borax, 
preferably  by  a  PoHtzer  bag  holding  8  oz.  So  soon^as  it  is  estimated 
that  I  oz.  has  been  injected,  the  stop-cock  of  the  bag  should  be  turned, 
and  the  water  allowed  to  run  out  of  the  catheter,  and  then  the  same 
procedure  repeated  until  the  return  water  runs  clear.  No  more  than 
I  oz.  should  be  injected  at  a  time,  because  it  should  be  remembered 
that  the  bladder  has  to  relax  very  slowly  in  health,  and  serious  injury 
has  been  produced  by  trying  to  inject  even  2  oz.  at  once.  Many 
authors  recommend,  after  the  bladder  has  been  washed  out,  the  use 
of  the  solution  of  silver  nitrate  in  the  proportion  of  i  :  8000  to  i  :  3000. 
When  the  bladder  seems  to  be  washed  clean  of  mucus,  i  oz.  of  the  solu- 
tion, to  which  I  to  3  gr.  of  resorcin  have  been  added,  should  be  injected 
to  remain  in  the  bladder,  the  resorcin  being  the  best  agent  that  I 
know  of  for  preventing  fermentation. 

PYELITIS,  OR  INFECTION  OF  THE  PELVES  OF  THE  KIDNEY 

PyeUtis  may  become  one  of  the  most  serious  of  conditions,  because 
it  is  due  to  both  primary  and  secondary  infection  by  micro-organisms. 
The  secondary  infections  are  usually  of  an  ascending  character  from 
an  inflamed  bladder,  notably  in  the  chronic  cystitis  of  elderly  patients 
with  enlarged  prostate.  It  should  always  be  remembered  that  an 
enlarged  prostate  threatens  the  patient  not  only  with  cystitis,  but 
with  consequent  ascending  infection  of  the  kidneys  through  the  ureter, 
which  then  first  develops  a  pyelitis,  and,  according  to  the  virulence  of 
the  infecting  micro-organisms,  spreads  through  the  caHces  and  be- 
tween the  pyramids  to  the  whole  organ,  inducing  in  many  cases  a 
true  pyonephrosis,  with  possibly  a  destruction  of  the  kidney,  forming 
a  well-defined  tumor  in  the  flank.  Catheterization,  which  is  often  so 
necessary  in  cases  of  urinary  obstruction  and  cystitis  from  enlarged 
prostate,  is  of  itself  a  constant  source  of  infection  by  micro-organisms, 
especially  if  the  catheters  have  not  been  properly  washed  and  cleansed 
in  aseptic  fluids  before  their  introduction.      It  is  impossible  to  ster- 


PYELITIS,    OR    INFECTION    OF    THE    PELVES    OF    THE    KIDNEY      439 

ilize  the  urethra,  and  hence  catheterization  is  ahnost  certain,  sooner 
or  later,  to  cause  infection  of  the  urinary  passages. 

Direct  inflammation  of  the  pelves  of  the  kidney  may  occur  from 
the  presence  of  gravel  and  render  them  more  susceptible  to  infection. 
The  commonest  micro-organism  for  inducing  pyelitis  is  the  Bacillus 
coli,  as  we  have  already  explained,  for  this  may  reach  the  kidney  both 
directly  from  the  blood  and  also  by  the  root  of  the  bladder.  Next 
to  the  Bacillus  coli  in  frequency  is  the  tubercle  bacillus,  which  may 
reach  the  kidney  by  the  same  variety  of  sources  as  tuberculosis  else- 
where, but  is  often  in  the  early  stages  most  evident  in  developing  about 
the  caHces  of  the  pelvis.  In  tubercular  kidneys  there  is  a  special 
tendency  to  hemorrhage  or  to  hematuria,  with  the  extension  of  the 
ulceration  subsequently  to  the  whole  organ,  and  leading  to  the  forma- 
tion of  small  abscesses,  owing  to  the  very  common  association  of  the 
pus  organisms  with  the  tubercle  bacillus. 

It  is  important  to  recognize  the  presence  of  pyelitis  as  early  as 
possible,  because  in  many  cases  its  forms  are  quite  amenable  to  medic- 
inal treatment  when  taken  in  their  earher  stages.  On  the  discovery 
of  the  pus  in  the  urine  it  should  be  determined  whether  it  comes  from 
the  bladder,  or  whether  from  the  ureter,  and  for  this  purpose  the  cysto- 
scope  should  be  used  to  test  which  ureter  is  involved.  PyeHtis  is 
infrequently  caused  by  the  administration  of  turpentine  or  cantharides 
or  similar  irritating  agents,  and  will  soon  subside  on  their  withdrawal. 

Treatment. — Pyelitis,  as  we  have  seen,  is  a  progressive  disease, 
which,  beginning  in  the  pelvis  of  the  kidney,  may  extend  so  as  to 
involve  and  destroy  the  whole  organ.  It  commonly  affects  only  one 
kidney,  and  hence  its  early  recognition  is  most  important,  for  in  its 
beginning  it  is  quite  amenable  to  medical  treatment,  because  various 
agents  are  readily  excreted  by  this  organ,  and  thus  act  more  locally 
than,  for  example,  in  the  case  of  the  lungs  or  even  of  the  intestinal 
tract. 

I  have  found  the  fluidextract  of  buchu  one  of  the  best  sedatives 
for  inflammatory  conditions  of  the  urinary  tract,  in  doses  of  a  dram, 
to  which  I  dram  of  liquor  potassse  may  be  added  if  the  urine  is  acid. 
In  pyelitis  I  always  add  a  teaspoonful  of  paregoric,  because  I  have 
found  this  an  admirable  adjunct  as  well  as  a  local  antiseptic  in  these 
cases.  This  prescription  may  be  given  every  three  hours,  or  oftener,  in 
severe  cases. 

I  once  cured  an  aggravated  case  of  tuberculous  kidney,  accom- 
panied both  by  hematuria  and  pyuria,  with  abundant  presence  of 
tubercle  bacilli,  but  no  cystitis,  by  the  above  prescription  of  buchu 


440  CLINICAL  MEDICINE 

and  paregoric,  on  account  of  kidney  pain,  and  the  administration  of 
15  gr.  of  creosote  carbonate  in  emulsion  every  three  hours  till  the  urine 
was  darkened  by  it.  The  pain  and  fever  subsided  in  two  months, 
and  the  tubercle  bacilli  disappeared  after  three  months,  though  the 
treatment  was  kept  up  for  a  year,  when  the  patient  wholly  recovered, 
and,  at  last  accounts,  was  well  twelve  years  after  the  original  attack. 

Urotropin,  as  might  be  expected,  is  also  an  efhcient  remedy  in  such 
cases.  I  have  not  found  the  large  doses  sometimes  recommended 
advisable,  because  this  drug,  by  itself,  occasionally  causes  much  local 
irritation.  This  can  be  obviated  by  the  simultaneous  administration 
of  sodium  benzoate,  as  mentioned  in  the  treatment  of  kidney  and 
bladder  infection  by  the  Bacillus  coH.  For  this,  as  then  stated,  lo-gr. 
doses  of  urotropin,  with  the  same  of  sodium  benzoate,  every  three 
hours  will  suffice. 

.  HYDRONEPHROSIS 

In  whatever  way  an  obstruction  occurs  in  a  ureter  the  secretion 
of  the  kidney  accumulates  behind  it,  with  resulting  changes,  varying 
according  to  the  nature  of  the  obstruction.  Thus,  a  movable  kidney 
may  cause  a  sac  to  be  formed  large  enough  to  appear  as  a  tumor,  which 
then  disappears,  with  a  sudden  flow  of  urine,  only  to  reaccumulate 
again  and  then  similarly  disappear.  In  some  cases  this  process  may 
go  on  for  years.  In  these  intermittent  cases  the  sac  may  in  time  be- 
come very  large,  and  so  fill  the  abdominal  cavity  as  to  be  mistaken  for 
ascites. 

When  the  obstruction  cannot  be  removed,  as  from  an  impacted 
calculus,  the  pelvis  of  the  ureter  is  first  dilated  and  then  general  dila- 
tation of  the  kidney  follows,  turning  it  into  a  cyst,  with  little  trace  of 
kidney  tissue  remaining.  As  this  is  an  acute  process  it  is  accom- 
panied by  much  pain  and  fever,  but  not  with  the  uremic  symptoms, 
because  the  other  kidney  takes  up  all  the  duties  of  its  fellow,  as  in  the 
case  mentioned  on  page  420.  Large  sacs  may  be  confounded  with 
ovarian  tumors,  and  aspiration  of  the  fluid  may  be  necessary  to  settle 
the  diagnosis,  the  puncture  being  made  in  the  flank,  between  the 
ilium  and  the  last  rib. 

Occasionally  hydronephrosis  is  caused  by  pressure  on  the  ureter 
from  without,  particularly  by  cancers  of  the  uterus  or  ovaries.  In 
some  cases  hydronephrosis  is  of  antenatal  origin,  the  destruction  of  the 
ureter  being  due  to  various  malpositions  of  the  pelvic  viscera.  The 
resulting  tumor  may  be  so  large  as  to  retard  labor.  Surgical  draining 
of  the  recurrent  tumor  is  the  only  recourse  in  such  cases. 


PERINEPHRIC   ABSCESS  44I 

PERINEPHRIC   ABSCESS 

No  illustration  could  be  better  of  the  difference  in  the  body  between 
an  accumulation  of  watery  fluid  and  a  collection  of  pus.  This  is  de- 
monstrated in  the  contrast  between  the  mere  water  collection,  such  as 
that  of  hydronephrosis,  just  spoken  of,  and  a  perinephric  abscess.  A 
watery  accumulation  can  do  no  harm,  except  occasionally  by  mere 
mechanical  pressure,  but  a  collection  of  pus  may  be  as  deadly  in  its 
results  as  an  explosion  of  dynamite.  Thus,  in  contrast  with  the 
hydronephrosis,  a  perinephric  abscess  may  make  its  way  up  to  the 
pleura  and  chest  into  the  lung;  or,  more  frequently,  it  may  pass  down 
the  psoas  muscle  and  appear  in  the  groin;  or  it  may  pass  along  the 
iliacus  fascia  and  appear  at  Poupart's  ligament;  or  it  may  perforate 
the  bowel;  or  it  may  break  into  the  peritoneum;  or  it  may  perforate 
the  bladder,  or  break  through  the  vagina. 

Consequently,  the  symptoms  may  be  very  varied  and  widespread, 
owing,  for  example,  to  pain  referred  to  the  hip,  and  radiate  down  the 
inside  of  the  thigh  and  cause  retraction  and  pain  in  the  testicle  on  that 
side.  If  the  patient  attempts  to  walk  he  has  much  difficulty  in  volun- 
tarily adducting  the  thigh;  he  also  keeps  the  spine  immobile  and  as- 
sumes a  stooping  posture,  and,  when  lying  in  bed,  he  has  to  draw  up 
one  leg  to  relieve  tension  upon  the  psoas  muscle.  From  proximity  of 
the  p.us  to  the  large  intestine  it  may  become  very  offensive  in  its  odor. 

These  clinical  facts  are  all  explicable  by  the  relation  of  the  kidney 
to  the  surrounding  parts,  because  this  organ  lies  in  an  extensive  mesh 
of  connective  tissue,  in  which  collections  of  pus  are  very  Joosely  held, 
and,  on  slight  provocation,  may  travel  in  any  direction,  with  the 
results  as  described.  It  is  important,  therefore,  that  this  condition 
be  early  recognized,  and  one  very  suggestive  sign  is  the  supervention 
of  hyperleukocytosis  in  the  blood.  Whenever  a  swelling  in  the  region 
of  the  kidney  is  accompanied  by  chills  and  fever  the  presence  of  a 
hyperleukocytosis  is  a  proof  of  the  development  of  an  abscess  in  that 
region. 

The  formation  of  a  perinephric  abscess  may  result  from  a  number 
of  different  causes;  thus,  a  common  cause  is  from  blows  or  injuries  in 
that  region,  or  the  extension  of  inflammation  from  the  pelvis  of  the 
kidney,  the  kidney  itself,  or  the  ureters,  or  from  perforation  of  the 
bowels  in  appendicitis,  or  extension  of  suppuration  from  the  spine  in 
caries;  in  tuberculous  disease  of  the  vertebrae,  but  occasionally  it  occurs 
from  extension  of  an  empyema  in  the  pleura,  or  it  may  be  a  sequel  in 
children  to  infective  fevers. 

On  examining  in  the  region  of  the  kidney,  a  swelling,  often  with  a 


442  CLINICAL  MEDICINE 

sense  of  fluctuation,  may  be  found  between  the  last  rib  and  the  crest 
of  the  ilium.  The  only  doubt  likely  to  occur  in  diagnosis,  especially 
in  children,  may  be  that  it  is  due  to  disease  of  the  hip- joint,  but  the 
pain  and  other  s3nnptoms  are  located  above  the  hip,  and  none  of  the 
distinctive  signs  of  hip-joint  disease  are  present. 

The  treatment  of  these  cases  is  always  surgical,  because  the  indica- 
tion to  drain  the  pus  without  delay  is  imperative. 

MORBID  CONDITIONS  OF  THE  URINE 

Indicanuria. — In  this  section  we  do  not  include  subjects  treated 
elsewhere,  such  as  glycosuria,  albuminuria,  pyuria,  and  hematuria. 

The  first  of  these  subjects  is  indicanuria.  This  designates  the 
presence  of  indican  in  the  urine,  as  demonstrated  by  reaction  with 
the  formation  of  indigo,  on  using  Jaffe's,  Obermeyer's,  or  similar  tests. 

Indol  is  absorbed  from  the  intestines,  and  forms  in  the  Uver  indoxyl 
potassium  sulphate  or  indican,  an  ethereal  sulphate  which  is  ehminated 
in  the  urine.  This  is  a  common  and  always  significant  condition,  due 
to  abnormal  putrefaction  in  the  intestines.  Progress  in  our  knowl- 
edge of  processes  of  intestinal  digestion  has  shown  that  many  serious 
disorders  proceed  from  this  cause,  one  of  which  is  revealed  by  an  excess 
of  indican  in  the  urine.  Thus,  when  we  investigate  the  steps  which 
lead  up  to  chronic  interstitial  nephritis,  and  then  to  the  development 
of  arteriosclerosis  with  all  its  attendant  evils,  we  find,  as  already 
mentioned  in  the  discussion  of  kidney  diseases,  that  such  affections  pro- 
ceed from  chronic  intestinal  disorders.  Prominent  among  these  intes- 
tinal disorders,  which  are  the  precursors  of  diseases  of  the  kidneys,  we 
must  now  assign  an  important  place  to  chronic  indicanuria. 

The  causes  of  indicanuria,  though  numerous,  may  yet  be  grouped 
together  as  due  to  faulty  digestion  of  the  nitrogenous  or  protein  articles 
of  food.  An  excess  of  meat  diet,  for  example,  is  one  of  the  causes  of 
indicanuria,  and  this  is  commonly  accompanied  by  constipation. 
Thus,  carnivora  have  much  less  bulky  movements  of  the  bowels  and 
less  frequent  than  herbivora,  but,  as  we  have  already  mentioned,  an 
excess  of  indican,  besides  leading  to  disorders  of  the  kidneys,  also  pre- 
disposes, by  absorption  of  poison  from  the  intestines,  to  convulsive 
nervous  disorders.  Hence,  carnivora  usually  die  in  convulsions,  while 
these  are  uncommon  among  herbivora. 

Treatment. — In  the  article  on  the  Treatment  of  Epilepsy  I  strongly 
condemned  the  use  of  a  hearty  meat  diet  in  that  disease  and  excluded 
all  butcher  meats  in  such  patients.  Indicanuria,  therefore,  should  not 
be  Hghtly  regarded,  and  its  presence  should  receive  the  serious  consider- 


MORBID   CONDITIONS    OF    THE   URINE  443 

ation  of  every  physician,  so  as  to  lead  promptly  to  its  removal  by  treat- 
ment, if  only  for  prophylaxis.  This  indication  is  first  met  by  regulat- 
ing the  diet,  for,  both  in  these  cases  and  those  of  chronic  nephritis,  red 
meats  should  be  excluded,  and  fermented  milk,  with  fruits  and  vege- 
tables, taken  instead. 

We  have  long  been  desirous  for  a  better  knowledge  of  the  morbid 
processes  which  precede  the  slow  development  of  interstitial  nephritis, 
along  with  it  the  supervention  of  arteriosclerosis,  not  in  one  part  of  the 
body  only,  but  all  over  the  system.  It  now  seems  almost  demonstrated 
that  chronic  intestinal  disorders  are  responsible  for  the  development  of 
both  these  general  systemic  conditions,  and  that  these  in  turn  are  due 
to  that  blood-poisoning  which  is  shown  by  excessive  indican  in  the 
urine. 

We  have  also  in  urotropin  an  effective  remedy  against  indicanuria, 
using  10  gr.  of  urotropin  and  10  gr.  of  sodium  benzoate,  taken  in  the 
form  of  powders,  an  hour  after  meals  and  at  night.  Some  cases  of 
severe  vomiting,  occurring  at  intervals  in  connection  wdth  high  arterial 
pressure,  can  be  stopped  only  by  prompt  medication.  Cases  are  re- 
ported (Kemp)  in  which  double  these  doses  of  urotropin  proved  to  be 
the  only  way  of  checking  this  complication. 

Lithuria. — This  condition  of  the  urine  we  have  already  spoken  of  in 
disorders  of  the  kidneys  accompanied  by  excess  of  uric  acid  or  gravel, 
to  which  the  reader  is  referred. 

Phosphaturia. — Excess  of  the  earthy  phosphates  in  the  urine  may 
be  detected  only  by  boiling  it,  when  a  cloud  forms  that  seems  Hke  coag- 
ulated albimiin  in  the  excretion.  That  this  appearance  is  due  not  to 
the  presence  of  albumin,  but  to  excess  of  phosphates,  is  shown  at 
once  by  adding  i  or  2  drops  of  strong  nitric  acid,  when  the  fluid  at 
once  clears  up.  In  some  cases  of  phosphaturia,  however,  the  urine 
when  passed  is  actually  milky  in  color;  the  reaction  as  tested  by  htmus- 
paper  may  be  either  neutral  or  actually  alkahne  and  of  low  specific 
gravity.  Phosphaturia  is  indicative  of  much  nervous  depression  on 
the  part  of  the  patients,  and  is  best  treated  by  taking  an  alcoholic 
drink,  though  always  with  meals. 

Chyluria.— I  once  had  a  patient  at  the  Roosevelt  Hospital  who 
passed  a  very  milky  looking  urine.  I  accordingly  had  his  blood  ex- 
amined in  the  evening,  and  found  in  it  the  characteristic  ova  nematoid 
worm  called  the  Filaria  Bancrofti.  When  the  same  blood  was  exam- 
ined at  10  o'clock  the  next  morning  no  ova  were  found,  and  so  re- 
peatedly afterward  such  examination  would  detect  the  nematoid's 
products  only  at  night,  but  not  during  the  day.     This  case  sufficiently 


444  '  CLINICAL  MEDICINE 

illustrates  the  peculiar  characteristics  of  this  infection,  which  is  rare 
in  our  country  excepting  in  our  Southern  States,  but  is  very  com- 
mon in  tropical  countries,  as  in  British  Guiana,  where  it  is  said  that 
58  per  cent,  of  the  people  are  so  affected.  It  is  now  plainly  demon- 
strated that  the  mosquito  first  sucks  blood  infected  by  this  parasite 
and  then  transmits  it  to  others,  just  in  the  way  malarial  organisms 
are  propagated.  Like  the  malarial  organism  also  the  blood  may  re- 
main infected  by  this  method  for  years,  and  yet  without  the  general 
health  being  much  impaired.  It  is  curious  that  this  organism  spreads 
through  the  system  only  during  sleep,  for  if  the  patients'  habits  of 
sleep  be  reversed  so  that  they  sleep  in  the  daytime  the  filaria,  instead 
of  charging  the  blood  at  night,  do  so  only  during  the  day. 

These  organisms  may  produce  their  effects  mainly  by  blocking  the 
Ijmaphatics  of  the  scrotum,  so  that  it  becomes  enormously  swollen. 
They  are  also  charged  with  producing  what  is  called  elephantiasis  of 
the  legs,  a  condition  found  in  tropical  countries,  of  which  I  have  seen 
two  marked  examples.  It  is  strange,  however,  that  in  neither  of  these 
conditions  were  there  any  other  morbid  symptoms. 

The  adult  male  measures  83  mm.  long  by  0.407  mm.  broad;  the 
tail  forms  two  turns  of  a  spiral.  The  adult  female  measures  155  mm. 
long  by  0.715  mm.  broad;  vulva  2.56  mm.  from  anterior  extremity; 
eggs  38  by  14  mm.  It  is  this  species  to  which  both  chyluria  and 
elephantiasis  are  ascribed. 

Chyluria,  on  examination,  shows  not  uncommonly  a  good  many 
blood-corpuscles  suspended  in  a  fluid,  whose  milkiness  is  due  to  minute 
globules  of  fat. 

My  own  belief  is  that  the  blood  can  be  freed  of  this  parasite  by  the 
free  administration  of  urotropin  with  sodium  benzoate,  from  40  to  80 
gr.  of  each  a  day.  Abstinence  from  all  fat  in  the  diet  often  causes  the 
disappearance  of  chyluria,  but  not  the  cure  of  the  disease.  Some  sur- 
geons report  favorable  results  from  excision  of  the  enlarged  lymphatic 
glands  in  the  groin. 

Some  very  rare  cases  are  reported  which  are  not  due  to  parasites, 
but  their  nature  is  doubtful. 

Cystinuria. — Cystin  is  one  of  the  unusual  products  of  protein 
metaboHsm  which  may  be  excreted  by  the  kidneys  and  even  form 
calcuH.  This  faulty  metabolism  generally  occurs  as  a  family  com- 
plaint, which,  in  minor  degree,  may  exist  without  disturbing  the 
general  health.  These  calculi  are  formed  of  crystals,  colorless  and 
hexagonal,  and  are  readily  detected,  and,  as  their  cause  is  unknown, 
their  treatment,  when  they  form  calcuH,  must  be  surgical. 


CYSTS    OF  THE   KIDNEY  445 

Melanuria,  or  black  urine,  may  have  a  very  serious  import  when 
caused  by  the  disintegration  of  melanotic  sarcomatous  tumors  in  the 
body.  In  some  cases  this  pigment  is  lodged  in  the  subcutaneous  tis- 
sues, of  which  I  have  seen  several  examples.  In  other  cases  the  urine 
becomes  dark  or  smoky  from  blood  in  the  urine,  and  also  to  a  small 
degree  in  hemoglobinuria.  The  commonest  cause,  however,  of  such 
darkening  is  from  drugs.  Thus  carbolic  acid  may  cause  it  and  a 
great  many  of  the  derivatives  of  the  coal-tar  series,  such  as  creosotal, 
sulphonal,  and  similar  substances,  when  they  are,  however,  of  but 
slight  significance. 

Bacterinuria. — The  commonest  examples  of  these  conditions  of  the 
urine  we  have  already  referred  to  in  our  article  on  the  Infections  by  the 
Bacillus  Coli,  in  which  we  described  the  hazy  appearance  of  the  urine 
due  to  the  excretion  into  it  of  immense  numbers  of  this  bacterium,  and 
which  may  occur,  either  primarily  or  secondarily  to  absorption  of  these 
bacteria,  from  ulceration  of  the  intestine  in  typhoid  fever,  the  treat- 
ment for  which  may  be  found  in  that  article. 

TUMORS  OF  THE  KIDNEY 

The  kidneys,  Hke  other  abdominal  organs,  may  be  invaded  by 
malignant  growths,  either  cancerous  or  sarcomatous.  The  com- 
monest condition  is  that  of  invasion  from  without,  and,  if  the  patient 
is  a  child,  it  is  almost  certainly  a  sarcoma.  When  small,  the  whole 
tumor  may  be  movable  and  the  diagnosis  relatively  easy,  because  the 
colon  lies  in  front.  When  it  is  large,  however,  adhesions  are  common, 
and  then  the  diagnosis  may  be  quite  difficult.  Occurrence  of  profuse 
hematuria  along  with  a  tumor  in  either  flank  is  decisive  of  the  malig- 
nant character  of  the  growth.  In  other  cases  the  diagnosis  may  be 
cleared  by  an  x-ray  picture,  showing  the  relative  positions  of  the 
parts.  If,  in  addition  to  this,  constitutional  symptoms  are  present, 
such  as  progressive  emaciation,  there  can  be  Httle  doubt  of  the  maUg- 
nant  nature  of  the  growth. 

Benign  growths  develop  in  the  kidneys,  usually  small  nodular 
fibromata,  occurring  about  the  pyramids. 

CYSTS  OF  THE  KIDNEY 

Occasionally,  though  rarely,  hydatids  form  cysts  in  the  kidney, 
as  already  mentioned  in  our  article  on  Hydatid  Disease.  But  the  com- 
monest form  is  polycystic  condition  of  the  kidney,  usually  bilateral, 
in  which  the  kidneys  are  very  much  enlarged,  and  are  found  after 
death  to  contain  hundreds  of  small  cysts,  the  origin  of  which  is  much 


446  CLINICAL  MEDICINE 

disputed;  the  most  probable  view  is  that  they  are  due  to  congenital 
faults  in  development,  because  such  cystic  kidneys  are  found  to  precede 
birth,  when  nearly  the  whole  abdominal  cavity  is  so  occupied  by  the 
tumor  as  to  obstruct  labor. 

I  once  saw,  at  postmortem,  the  kidney  transformed  into  masses 
not  unlike  a  large  bunch  of  grapes. 

MOVABLE  KIDNEY 

Some  years  ago  we  used  to  hear  much  about  the  various  troubles  oc- 
casioned by  movable  kidney,  and  many  symptoms  were  associated  with 
such  displacements.  We  hear  less  about  them  now,  but  they  undoubt- 
edly do  occur,  for  every  practitioner  is  apt  to  find  one  kidney  at  a 
considerable  distance  from  its  right  place  and  at  the  same  time  very 
movable.  It  is  well  not  to  tell  the  patient  about  such  abnormahties, 
because  they  may  go  through  life  without  suffering  any  inconvenience 
from  them. 

Displacement  of  the  kidney  frequently  coexists  with  the  falHng 
down  of  the  abdominal  organs  or  gastroptosis,  called  Glenard's  dis- 
ease. But  there  can  be  no  doubt  that  such  displacements  may  some- 
times produce  severe  symptoms,  described  as  Dietl's  crises,  which  are 
best  explained  by  kinks  in  the  ureter  leading  from  the  displaced  kidney. 
These  attacks  are  characterized  by  severe  pain,  accompanied  by  nausea 
and  sometimes  by  vomiting,  and  which  are  finally  cured  only  by  stitch- 
ing the  displaced  kidney  to  the  abdominal  wall.  Previous  to  this  the 
trouble  may  be  wholly  relieved  by  Rose's  belt  for  gastroptosis,  as 
previously  described,  or  by  using,  if  properly  applied,  an  abdominal 
supporter. 

Displacement  of  the  kidney  is  apt  to  occur  where  the  abdominal 
walls  are  left  lax  and  pendent  after  repeated  pregnancies.  They  are 
more  common  on  the  right  side,  as  the  kidney  there  Hes  directly  under 
the  liver.  The  diagnosis  is  usually  easy  by  having  the  patient  He  on 
the  back  with  the  knees  drawn  up,  so  as  to  relax  the  walls  of  the 
abdomen,  and,  with  one  hand  under  the  ribs  behind  and  the  other  in 
front,  when,  by  palpation  on  the  under  surface  of  the  liver,  the  lower 
part  of  the  kidney  may  be  easily  felt,  particularly  on  deep  inspiration. 

In  conditions  of  true  movable  kidney  the  whole  organ  may  thus  be 
made  palpable. 


CHAPTER  XI 

DISEASES  OF  METABOLISM 

GOUT 

Clinical  facts  furnish  much  more  trustworthy  information  than 
any  chemical  theories  about  the  nature  of  gout.  Thus,  there  has  been 
a  great  deal  written  about  the  metabohsm  of  the  so-called  purin 
bodies — adenin,  guanin,  hypoxanthin,  xanthin,  and  uric  acid — re- 
sulting from  the  transformation  of  the  nucleoproteins  of  the  food 
and  of  the  tissues,  but  against  these  stands  the  fact  that  gout 
is  unknown  in  countries  where  no  fermented  liquors  are  used.  It  is, 
therefore,  not  alcohol  which  causes  gout,  because  in  countries  which 
are  noted  for  excess  in  the  use  of  spirituous  Hquors  every  disease  which 
alcohol  produces  is  sure  to  be  common  except  gout.  Thus,  in  England 
it  may  be  termed' "pandemic,"  on  account  of  the  historic  as  well  as 
present  consumption  there  of  beers  and  ales,  but,  on  crossing  the  Tweed 
into  Scotland,  we  find  whisky  to  be  a  universal  drink,  without  its 
giving  rise  to  gout.  In  America  gout  used  to  be  quite  an  aristocratic 
disease  and  complacently  referred  to  by  its  victims  as  a  sign  of  their 
taking  high  priced  Port  or  Madeira  wines,  otherwise  whisky  was  the 
American  drink.  On  the  introduction,  however,  of  lager  beer  into 
the  United  States  gout  became  a  very  plebeian  affection,  though  it  is 
yet  practically  unknown  in  those  parts  of  the  country  which  consume 
only  whisky.  Previous  to  the  introduction  of  lager  beer  gout  was 
prevalent  in  this  country  only  among  those  who  drank  one  of  the  most 
potent  agents  for  its  production — namely,  cider. 

The  word  "metabohsm"  covers  a  multitude  of  unknown  things. 
That  fermented  Hquors  should  cause  gout  and  distilled  hquors  do 
not  confirms  the  statement  of  Sir  A.  Garrod,  that  if  there  were  no  fer- 
mented liquors  there  would  not  be  any  gout.  This  cHnical  fact  cannot 
be  accounted  for  by  the  chemistry  of  uric  acid.  Moreover,  all  diseases 
accompanied  by  an  excess  of  white  corpuscles,  as  in  leukemia,  show  a 
corresponding  increase  in  uric  acid,  but  without  producing  goat. 
Chemically  speaking,  the  insoluble  uric  acid  should  be  oxidized  into 
the  soluble  urea,  but  in  birds,  whose  respiration  is  so  active  that  they 
should  oxidize  without  hmit,  nevertheless  they  excrete  not  urea,  but 

447 


448  CLINICAL  MEDICINE 

uric  acid.  It  is  medical  experience  which  shows  that  in  gouty  persons 
there  is  an  excess  of  uric  acid  in  the  blood,  and,  as  the  blood  must  be 
alkaline,  this  acid  combines  with  the  soda  there  in  the  form  of  the 
biurate  of  soda. 

Gout,  however,  furnishes  a  strong  argument  against  Weismann's 
theory  that  acquired  systematic  habits  are  not  transmitted,  for  it  is 
notorious  that  gout,  once  acquired,  is  very  apt  to  pass  on  and  become  a 
hereditary  disease  in  the  descendants,  though  more  apt  to  be  transmit 
ted  through  the  female  line  than  through  the  male.  Thus,  a  man  may 
inherit  gout  from  his  grandfather  through  his  grandmother,  who  her- 
self did  not  suffer  from  the  disease. 

The  biurate  salt,  however,  is  insoluble,  and  clinically  causes  gouty 
arthritis  in  its  own  particular  way.  Thus,  at  first  it  has  no  resem- 
blance to  rheumatic  arthritis  in  the  joints  which  are  affected  by  it. 
As  all  inflammations  of  joints  produce  very  much  the  same  symptoms, 
so  a  rheumatic  arthritis  and  a  gouty  arthritis  are  often  confounded, 
but  the  clinical  histories  of  the  cases  differ  characteristically.  Rheu- 
matic arthritis  is  polyarticular  from  the  beginning,  and,  though  it  may 
begin  in  the  feet,  it  is  sure  to  attack  the  joints  of  the  upper  extremities 
as  well,  such  as  the  fingers,  wrists,  and  shoulders.  Gouty  arthritis, 
on  the  other  hand,  is  at  first  monarticular,  developing  .most  commonly 
in  the  great  toe,  and  it  may  remain  for  several  years,  attacking  the 
lower  extremities.  Once,  however,  it  involves  the  knee,  it  then  be- 
comes distributed  over  all  the  joints,  with  the  exception  of  the  jaw 
and  the  sterno-articular  joints. 

There  are,  however,  many  pecuHarities  presented  by  gouty  ar- 
thritis. The  skin  over  the  joints  also  becomes  inflamed,  so  that  on 
the  subsidence  of  the  inflammation  it  peels,  which  it  never  does  with 
a  rheumatic  inflammation.  It  should  be  remembered  that  a  rheu- 
matic inflammation,  however  severe  or  prolonged,  does  not  perma- 
nently fetter  the  joints.  The  restoration  of  long-standing  inability 
of  the  joints  to  be  moved  after  rheumatic  inflammations  is  always 
practicable  by  douching  the  joints  with  hot  water  and  the  simul- 
taneous use  of  massage  and  movement.  Gout,  however,  when  it 
attacks  a  joint  almost  invariably  leaves  a  deposit  of  sodium  biurate 
in  the  cartilage  or  in  the  synovial  sheaths,  and  a  joint  once  distorted 
by  gouty  deposits  cannot  be  restored. 

When  gouty  inflammations  are  widely  distributed  it  may  be  diffi- 
cult to  distinguish  them  from  rheumatic  arthritis,  but  I  once  drew 
attention  to  the  marked  difference  in  the  painful  points  on  pressure 
in  the  joints  of  the  two  affections.      In  gout  the  painful  points  are  at 


GOUT  449 

the  condyles  of  the  knee,  for  example,  and  at  the  ends  of  the  transverse 
diameter  of  the  joints  of  the  fingers,  but  in  rheumatism  the  most  pain 
is  felt  along  the  course  of  the  tendons.  Thus,. in  a  gouty  knee  the  pain- 
ful points  are  at  each  condyle,  while  in  a  rheumatic  knee  it  is  above  and 
below  the  patella.  Similarly,  these  points  differ  in  the  fingers,  where 
in  rheumatism  the  pain  on  pressure  is  most  pronounced  along  the 
tendons;  in  gout  it  is  Umited  to  the  ends  of  the  transverse  diameters 
of  the  joints. 

Gouty  deposits  are  often  diagnostic,  as  in  those  accretions  found  in 
the  external  ear,  called  tophi.  These  may  be  found  there  when  no 
other  deposits  can  be  discovered  in  the  body.  Gouty  deposits  about 
a  joint  are  often  very  general,  beginning  with  the  surfaces  of  the 
articular  cartilage  and  then  extending  to  the  ligaments,  fasciae,  ten- 
dons, and  synovial  membranes.  In  some  cases  they  may  involve  the 
skin,  which  may  ulcerate  and  leave  the  gouty  deposits  exposed. 

Besides  the  articular  affections,  gout-Hke  rheumatism  may  affect 
internal  structures  not  connected  with  joints,  but,  though  acute 
rheumatism  seriously  affects  the  heart,  gout  almost  never  does  so  as 
a  primary  affection.  On  the  other  hand,  while  rheumatism  does  not 
affect  the  kidneys,  gout  causes  one  of  the  most  serious  of  all  renal 
diseases. 

When  gouty  kidneys  are  cut  open  gouty  deposits  of  uratic  matter 
are  seen  on  the  cut  surfaces.  In  the  cortical  substance  the  deposit 
occurs  as  specks,  scattered  irregularly  through  the  tissue,  but  in  the 
pyramidal  portion  the  matter  is  in  strips,  running  in  the  direction  of 
the  tubuli.  In  both  cases  the  deposit  is  situated  in  the  intertubular 
substance,  and,  when  examined  imder  the  microscope,  is  seen  to  consist 
of  acicular  crystals  exactly  resembUng  those  found  in  gouty  joints. 
The  kidneys  are  granular,  and  closely  resemble  the  conditions  found 
in   ordinary  interstitial  nephritis. 

Besides  these  disorders  there  are  many  others,  both  functional 
and  organic,  which  are  classed  under  the  head  of  irregular  gout.  Thus, 
we  may  have  gouty  ophthalmia,  which  may  be  controlled  only  by 
administering  the  specifics  for  gout. 

Gouty  bronchitis  is  one  of  the  manifestations  of  irregular  gout. 
Its  onset  may  be  very  sudden.  I  was  once  called  in  at  night  to  a  lady 
whom  I  had  long  known  as  a  victim  of  hereditary  gout,  when  I  found 
fine  mucous  rales  over  both  lungs,  and,  in  the  course  of  two  hours,  she 
expectorated  a  large  basinful  of  pinkish-colored  mucus.  This  bronchi- 
tis often  cannot  be  distinguished  from  ordinary  chronic  bronchitis, 
but  tjie  discovery  of  a  gouty  element  in  the  case  may  hasten  the  re- 

29 


450  CLINICAL  MEDICINE 

covery  by  adding  to  other  remedies  colchicum  and  potassium  iodid. 
An  attack  of  gouty  arthritis  may  have  many  prodromata,  the  patient 
feels  dyspeptic,  and  not  uncommonly  much  depressed  in  spirits,  and 
some  persons  are  able  to  predict  that  they  will  have  a  joint  develop- 
ment in  the  course  of  a  few  days  by  the  supervention  of  such  symp- 
toms, which  all  clear  up  after  the  onset  of  the  arthritis.  It  is  a  curious 
fact  which  has  long  been  observed  that  the  output  of  uric  acid  dimin- 
ishes during  the  intervals  between  attacks  of  gout,  to  return  to  normal, 
or  excess  of  normal,  immediately  after  a  visit  of  gout. 

Treatment. — The  effective  treatment  of  an  attack  of  acute  gout  is 
the  administration  of  the  wine  of  the  root  or  of  the  wine  of  the  seeds 
of  the  meadow  saffron,  called  colchicum,  a  native  of  Europe  and  of 
Asia.  Colchicum  is  the  only  drug  of  vegetable  origin  which  can  pro- 
duce permanent  constitutional  effects.  (See  Difference  Between 
Functional  and  Constitutional  Remedies  in  the  chapter  on  Remedies.) 
An  instance  of  this  was  related  to  me  by  Dr.  Norwood,  of  Alabama,  to 
whom  the  profession  is  indebted  for  the  introduction  of  veratrum  viride. 
He  said  that  some  young  men  in  his  neighborhood  when  on  a  lark 
broke  into  the  office  of  a  country  practitioner  while  the  doctor  was  away, 
and,  after  mixing  up  his  drugs  so  that  he  could  not  use  them,  they  drank 
to  the  doctor's  health  from  a  bottle  which  contained  colchicum  wine. 
It  was  not  long  before  they  were  very  anxious  for  the  doctor's  return. 
One  of  them  died  from  the  effects,  while  the  others,  after  more  than  a 
week's  illness,  turned  universally  yellow,  and  lost  every  particle  of 
hair  on  their  bodies,  including  their  eyebrows.  This  is  very  similar 
to  the  effect  of  the  cobra  venom,  as  I  have  personally  seen  in  the  East. 

We  have  no  means  of  judging  how  colchicum  produces  its  effects 
any  more  than  other  alteratives.  It  is  a  virulent  poison,  which  shows 
its  effects  by  causing  severe  gastritis  and  enteritis,  so  that  nothing  will 
stay  on  the  stomach,  while  the  stools  become  bloody.  It  also  causes 
great  irritation  of  the  kidneys.     Death  ensues  from  heart  failure. 

In  the  treatment  for  an  attack  of  acute  gout  by  colchicum  the  drug 
should  be  administered  in  doses  of  from  15  to  20  drops  of  the  wine  of 
colchicum  seed,  with  slightly  lower  doses  of  the  wine  of  colchicum 
root,  given  every  two  or  three  hours.  As  a  rule,  the  severity  of  the 
arthritic  pains  and  swelling  subsides,  a  result  which  no  other  known  drug 
can  secure.  It  does  not  show  the  same  effects  in  chronic  or  irregular 
gout,  but  may  be  used  whenever  this  form  of  gout  takes  on  acute 
development.  I  have  not  found  this  medicine  to  be  efficacious 
when  it  loosens  the  bowels,  and  prescribe  from  i  to  2  drams  of  pare- 
goric to  prevent  this  action.     In  chronic  gout  the  action  of  colchicum 


DIABETES    MELLITUS  45 1 

is  promoted  by  the  simultaneous  administration  of  2  gr.  of  quinin  six 
times  a  day,  or  of  10  to  15  gr.  of  phenacetin.  There  can  be  no  doubt 
that  many  patients  are  also  helped  by  the  simultaneous  administra- 
tion of  small  doses  of  3  to  5  gr.  of  potassium  iodid,  while  others  are  still 
more  benefited  by  the  administration  of  small  doses  of  arsenic,  either 
in  3-  to  4-drop  doses  of  Fowler's  solution,  or  2V  gr.  of  the  arsenite  of 
soda.  Some  authors  recommend  that  gout  is  benefited  by  diminish- 
ing the  intake  of  common  salt. 

There  is  a  nostrum  called  Laville's  extract,  which  I  have  often  found 
successful  when  other  remedies  have  failed;  the  active  principle  of  this 
preparation  is  undoubtedly  colchicein,  combined  with  various  vegetable 
substances.  I  have  prescribed  it  in  doses  of  a  dram  of  Laville's  extract 
with  a  dram  of  the  ehxir  of  cinchona,  in  doses  of  from  i  to  2  tea- 
spoonfuls  twice  a  day,  and  have  found  this  beneficial  in  chronic  gout 
when  colchicum  itself  had  failed. 

DIABETES  MELLITUS 

The  subject  of  gout  introduced  us  to  the  wide  subject  of  metaboKsm. 
But  gout  is  nothing  compared  with  diabetes  in  doing  the  same  thing. 
More  than  fifty  years  ago  Dr.  J.  B.  Dalton,  in  the  preface  to  his  then 
leading  book  on  physiology,  stated  that  the  recent  discovery,  by 
Claude  Bernard  in  1857,  of  the  glycogenic  function  of  the  liver  prom- 
ised to  reveal  the  true  nature  of  diabetes.  Since  that  time  many 
facts  relating  to  this  subject  have  been  discovered,  but  diabetes  mel- 
litus  itself  remains  as  great  a  mystery  as  ever.  We  hear  of  bread 
being  the  staff  of  life,  but  to  a  diabetic  bread  is  a  deadly  poison.  This 
only  illustrates  what  a  calamity  it  is  to  suffer  from  diabetes,  because 
so  far  true  diabetes  is  incurable,  and  its  doom  is  death. 

This  statement  becomes  natural  when  we  recognize  what  the  fun- 
damental facts  about  diabetes  are.  The  muscles  are  the  furnaces 
of  the  body,  supplying  to  it  both  heat  and  power.  The  blood  in  the 
veins  flowing  from  a  large  muscle,  like  the  gluteus  maximus,  is  much 
more  venous  in  its  character,  though  the  muscle  be  at  rest,  than  the 
blood  in  the  right  chamber  of  the  heart.  This  shows  how  much  of 
something  has  been  burned  up  in  the  muscle  while  the  blood  was  cours- 
ing through  it.  That  something,  we  now  know,  is  the  carbohydrate 
in  our  food,  composed  of  the  starches,  sugars,  and  fats.  It  is  in  the 
combustion  of  these  elements  of  our  food  in  the  muscles  that  we  find 
the  source  of  the  heat  and  of  power  which  the  body  requires  for  its 
Hfe,  but  in  diabetes  the  muscular  tissues  do  not  sufficiently  burn  up 
the  carbohydrates.     These  have  been  before  properly  changed  into 


452  CLINICAL  MEDICINE 

the  most  easily  consumed  of  carbohydrates — viz.,  sugar — and  as  the 
muscles  fail  to  oxidize  it  the  sugar  accumulates  in  the  blood  until  it  is 
beyond  what  the  blood  can  carry — viz.,  .15  per  cent.  All  above  this 
has  to  be  got  rid  of  by  the  kidneys,  causing  glycosuria  or  sweet-tasting 
urine.  Glycosuria  is,  therefore,  the  first  sign  of  diabetes,  and,  when 
it  is  found,  no  one  can  be  sure  whether  it  will  go  on  to  full  diabetes  or 
not.  Often  glycosuria  can  be  made  to  disappear,  either  by  lessening 
the  intake  of  carbohydrates  or  by  drugs,  so  that  some  speak  Hghtly  of 
the  appearance  of  sugar  in  the  urine  as  not  itself  of  much  importance. 
One  might  as  well  say  that  fever  is  a  trivial  sign,  because  it  is  so  often 
transient  and  moderate  in  degree.  The  presence  of  glycosuria  is 
always  a  danger-signal. 

The  carbohydrates  never  make  tissue,  but,  on  the  other  hand,  they 
have  to  go  through  various  processes  before  they  can  be  burned  up. 
The  first  is  their  conversion  into  glycogen,  in  which  form  they  are 
stored  up  in  the  Uver  and  also  in  the  muscles.  The  storage  of  glycogen 
in  the  liver  is  estimated  as  one-tenth  its  weight.  Bernard,  on  its  first 
discovery  by  him,  correctly  said  that  the  final  change  of  glycogen  is 
for  fuel  in  the  muscles. 

We  have  said  that  various  processes  of  preparation  are  necessary 
for  the  glycogen  to  be  burned  up  by  the  muscles;  the  principal  of  these 
preparatory  processes  is  by  the  action  of  the  internal  secretion  of  the 
ductless  glands,  the  deficiency  of  which  will  suffice  to  cause  the  sugars 
to  escape  combustion  and  thus  to  produce  glycosuria.  The  most 
striking  illustration  of  this  is  furnished  by  the  glands  embedded  in  the 
substance  of  the  pancreas,  called  islands  of  Langerhans.  These  glands 
have  nothing  to  do  with  the  functions  of  the  pancreas  itself.  Their 
relations  instead  are  with  the  metabolism  of  the  carbohydrates,  and 
it  is  not  owing  to  the  mere  quantity  of  their  secretions  that  their  spe- 
cific effect  is  produced,  for  if  only  a  few  of  these  glands  in  the  tail  of  the 
pancreas  remain  when  the  pancreas  itself  has  been  cut  away  those 
few  glands  answer  all  the  purposes  of  preventing  glycosuria.  More- 
over, it  has  been  shown  by  experiments  on  dogs  that,  if  the  pancreas 
be  removed  entirely  and  a  small  portion  of  the  pancreas  of  another 
dog  be  engrafted  in  the  course  of  the  portal  circulation,  this,  in  turn, 
will  prevent  the  development  of  glycosuria.  This  clearly  proves  that 
all  the  islands  of  Langerhans  do  is  to  produce  an  enzyme,  however 
minute  in  quantity,  which  will  answer  all  the  purposes,  just  as  a  single 
match  will  set  fire  to  a  large  accumulation  of  combustibles.  Cases, 
however,  do  occur  in  which  the  fuel  is  not  combustible,  and  then  it 
would  be  useless  to  apply  any  number  of  matches  to  start  the  fire. 


DIABETES   MELLITUS  453 

The  secretion  of  other  ductless  glands  can  also  bear  the  same 
relation  to  the  metaboHsm  of  the  carbohydrates.  This  is  shown  in 
that  most  remarkable  organ  in  the  body,  the  pituitary  gland,  called 
also  the  hypophysis.  This  small  body,  which  weighs  altogether  only 
about  5  gr.,  is  located  in  the  most  inaccessible  part  of  the  skull,  the 
sella  turcica,  and  yet,  notwithstanding  its  small  size,  it  bears  impor- 
tant relations  to  the  nutrition  of  the  body,  shown  in  the  hypertrophy  of 
the  bones  of  the  extremities  and  of  the  face  in  acromegaly.  Injuries 
to  the  base  of  the  skull  are  often  followed  by  glycosuria,  which  may 
also  appear  when  a  tumor  is  growing  in  the  neighborhood  of  this 
gland  and  irritating  it.  Should  the  tumor,  however,  destroy  the  gland, 
we  then  find  the  opposite  of  glycosuria  developing,  for  the  patient  can 
now  show  great  tolerance  for  sugars,  and,  along  with  this,  a  marked 
increase  in  the  fat  all  over  the  body. 

Glycosuria  or  true  diabetes  may  also  develop  in  diseases  of  that 
other  ductless  gland,  the  thyroid,  and  then  soon  prove  fatal.  It 
has  long  been  known,  however,  that  the  ductless  glands  are  all  associ- 
ated in  their  funcrions,  so  that  they  are  found  to  be  enlarged  or  diseased 
in  common  m  the  same  person.  As  to  the  relation  of  the  ductless 
glands  to  the  production  of  diabetes  there  is  Httle  doubt  that  it  is  the 
same  as  that  which  we  have  described  in  connection  with  the  islands 
of  Langerhans— viz.,  that  their  functions,  though  necessary,  are 
simply  preparatory  to  the  ultunate  use  of  the  carbohydrates  by  the 
muscles.  The  conclusion,  therefore,  is  that  diabetes  is  prhnarily  a 
muscular  disease,  but  how  it  is  so  is  yet  unknown. 

Claude  Bernard  demonstrated  that  there  is  a  center  m  the  medulla 
puncture  of  which  causes  an  increased  percentage  of  sugar  in  the  blood 
of  the  hepatic  vein.  He  demonstrated  that  the  efferent  path  of  this 
influence  was  in  the  splanchnic  nerves  and  the  afferent  in  the  vagi. 
There  can  be  no  doubt  that  the  nervous  system  has  much  influence  on 
liver  metaboKsm,  but  the  mechanism  of  this  action  is  unknown,  like 
many  other  problems  in  diabetes.  I  had  a  close  friend,  in  whom  fatal 
diabetes  followed  upon  a  long  mental  strain  during  a  painful  crisis  of 
his  Hfe,  with  no  other  cause  for  his  disease  which  was  discoverable. 

Diabetes  goes  by  contraries.  Ordinarily,  youth  is  the  age  with  the 
best  outiook  for  the  future,  but  in  diabetes  the  prognosis  is  invariably 
worse  the  younger  the  patient,  and  steadily  improves  with  advancing 
years.     With  young  children  it  is  soon  fatal. 

It  is  curious  that,  though  the  hver  holds  the  greatest  store  of  gly- 
cogen in  the  body,  yet  diabetes  of  hepatic  origin  is  unknown.  The 
liver  may  be  damaged  either  by  accident  or  disease,  as  in  cirrhosis, 


454  CLINICAL  MEDICINE 

with  no  trace  of  consequent  diabetes.  The  same  is  true  of  the 
kidneys. 

Though  the  kidneys  have  so  much  work  to  do  in  the  polyuria 
which  carries  off  the  sugar  in  the  blood,  yet  diabetes  itself  is  not  associ- 
ated with  kidney  disease.  Men  are  more  frequently  affected  with 
diabetes  than  women,  the  ratio  being  about  3  to  2.  Diabetes  is  a 
disease  of  the  higher  classes.  Von  Noorden  states  that  the  statis- 
tics for  London  and  Berlin  show  that  the  number  of  cases  in  the  upper 
10,000  exceeds  that  in  the  lower  10,000  inhabitants.  As  to  race, 
Jews  seem  to  be  especially  prone  to  it;  one-fourth  of  Friedreich's 
patients  were  of  this  Semitic  race.  In  my  own  experience,  Hebrews 
are  particularly  prone  to  the  disease,  and  in  them  women  are,  if  any- 
thing, more  subject  to  it  than  men. 

In  severe  cases  of  diabetes  the  disease  may  go  on,  though  all  car- 
bohydrates have  been  removed  from  the  diet.  The  continuance  of 
diabetes  in  them,  however,  is  due  to  the  destruction  of  the  proteins 
in  addition  to  the  carbohydrates  of  the  body  itself.  While  this  is 
occurring  there  is  a  marked  increase  in  the  urea  ehminated  from  the 
body.  I  have  been  accustomed,  therefore,  to  regard  the  percentage 
of  urea  as  a  good  standard  for  estimating  the  gravity  of  the  complaint. 
I  have  thought  that  I  had  reason  to  believe  in  the  existence  of  a  pure 
urea  diabetes,  and  in  a  published  paper  I  termed  these  patients  cases 
of  azoturia  in  which  the  urine  showed  a  great  excess  of  urea  without  the 
accompaniment  of  sugar.  These  patients  are  always  of  a  neurotic 
temperament.  One  young  man  passed  1750  gr.  of  urea  in  a  day.  He 
had  one  brother  who  was  insane  and  a  sister  who  was  both  hysteric  and 
abnormally  fat.  I  have  found  these  patients  respond  favorably  to 
the  administration  of  intestinal  antiseptics. 

While  there  seems  to  be  no  difficulty  in  disposing  of  the  proteins 
in  diabetes,  it  is  quite  otherwise  with  the  fats  which  are  not  suflEiciently 
oxidized,  the  result  being  the  formation  of  beta-oxybutyric  acid  in  the 
blood,  which  is  the  immediate  precursor  of  acetone  and  diacetic  acid, 
the  accumulation  of  which  in  the  blood  causes  the  fatal  diabetic  coma 
from  actual  acidosis.  Efforts  to  counteract  this  acidity  by  large  doses 
of  sodium  carbonate,  whether  by  mouth  or  by  the  rectum  or  by  intra- 
venous injection,  are  almost  universally  unavailing. 

The  general  lowering  of  the  vitahty  caused  by  diabetes  renders  the 
body  very  susceptible  to  various  infections;  chief  among  them  is  the 
tubercle  bacillus,  which  carries  off  a  large  number  of  diabetics.  Thus, 
also  the  pneumonias  of  diabetics  are  prone  to  become  caseous  or  else 
terminate  in  gangrene.     Pus  organisms  also  are  apt  to  invade  the 


DIABETES    MELLITUS  455 

skin,  particularly  the  Staphylococcus  pyogenes  aureus,  which  gives 
rise  to  numerous  boils  or  large  carbuncles.  Every  case  of  large  car- 
buncle should  have  the  urine  examined  for  the  presence  of  sugar. 
In  many  instances  there  is  a  great  deal  of  itching  of  the  skin,  and  in 
women  obstinate  irritation  of  the  pudenda.  This,  in  fact,  may  be  the 
first  indication  of  the  presence  of  diabetes. 

Symptoms. — Diabetes  is  usually  insidious  in  its  onset,  the  patient 
first  noticing  that  he  is  passing  more  water  and  more  frequently. 
Along  with  this  he  has  often  an  abnormal  appetite  or  a  sense  of  hun- 
ger. After  a  time  he  further  notices  that  he  is  more  easily  fatigued 
than  is  usual  with  him  on  exertion.  Emaciation  also,  in  a  majority  of 
cases,  sets  in  soon  after  the  polyuria.  All  along  he  is  thirsty,  and  when 
the  disease  is  fully  estabhshed  the  thirst  becomes  specially  distress- 
ing about  two  hours  after  meals.  In  addition,  he  becomes  very  ner- 
vous and  frequently  irritable  or  else  melanchoKc.  The  skin  is  ordi- 
narily dry  and  harsh,  unless  the  patient  is  phthisical.  One  of  the  most 
striking  symptoms  is  the  appearance  of  the  tongue,  which  has  more 
than  once  suggested  the  disease  to  me.  It  is  red  all  over,  and  has  been 
called  the  beefy  tongue.  In  advanced  cases  the  breath  has  a  sweet 
odor,  and,  in  my  experience,  this  symptom  is  of  serious  import.  As 
a  rule,  the  bowels  are  constipated.  These  patients  are  frequently 
depressed  in  spirits,  and  not  uncommonly  show  peripheral  neuritis, 
which  usually  is  local,  involving  a  nerve  of  the  arm  or  occasionally  the 
sciatic  nerve.  Cramps  in  the  calves  of  the  legs  are  very  common,  and 
lumbar  pains,  which  may  be  mistaken  for  lumbago,  the  distinction 
being  that  the  pains  are  not  aggravated  by  bending  of  the  spine,  which 
they  always  are  in  lumbago.  Along  with  the  lumbar  pains,  particu- 
larly in  elderly  patients,  there  is  complete  absence  of  the  knee-jerk. 
A  number  of  reports  have  been  pubUshed  of  postmortem  examinations 
of  the  spinal  cord,  showing  the  degeneration  of  the  posterior  columns, 
similar  to  the  findings  in  tabes. 

Complications. — General  bronchitis  is  always  of  serious  import, 
and  may  be  wholly  independent  of  any  infection,  tuberculous  or  other- 
wise. Connected  with  the  respiratory  tract  is  a  specific  dyspnea, 
called  by  Kussmaul  air-himger.  One  form  of  this  is  quickly  fatal, 
and  is  connected  with  fat  embolism,  caused  by  the  presence  of  small 
particles  of  fat  in  the  blood,  which  may  even  be  accompanied  by  a 
creamy  coat  upon  the  blood-clot.  The  origin  of  this  lipemia  is  quite 
obscure.  Where  the  blood  has  been  drained  of  its  watery  elements 
by  excessive  polyuria  there  may  be  an  apparent  great  increase  in  the 
red  corpuscles,  amounting  from  between  7,000,000  and  8,000,000  to  the 


456  CLINICAL  MEDICINE 

cubic  millimeter.  .Notwithstanding  this  the  intake  of  oxygen  and  the 
outgo  of  carbonic  acid  is  diminished.  As  a  rule,  therefore,  the  tempera- 
ture of  the  body  is  lowered  to  96°  or  even  95°  F.  All  vital  functions 
are  likewise  depressed,  presaging  the  end  in  diabetic  coma.  This  may 
set  in  with  varying  antecedents,  and  the  patient  may  suddenly  com- 
plain of  headache  and  become  thick  in  his  speech  and  staggering  in  his 
gait.  Soon  after  he  complains  of  great  weakness,  and  may  die  in  a  few 
hours  after  an  antecedent  stuporous  condition. 

Our  treatment  of  diabetes  must  be  wholly  empiric,  owing  to  our 
ignorance  of  the  pathology  of  the  disease.  Thus,  as  we  have  re- 
marked, there  is  no  accounting  for  the  fact  that  the  younger  the  patient 
the  more  hopeless  the  case,  while  the  prospect  becomes  better  and  he 
becomes  more  amenable  to  treatment  in  proportion  to  his  advancing 
years.  Other  facts  also  in  the  history  of  this  complaint  are  equally 
inexphcable,  which  are  reported  by  quahfied  medical  observers  from  a 
number  of  sources. 

Patients  with  severe  and  chronic  diabetes,  until  even  dangerous 
acidosis  is  present,  have  wholly  recovered  after  surgical  operations, 
such  as  those  about  the  prostate  in  males  and  ablation  of  the  uterus 
in  females.  Such  occurrences  are  absolutely  inexphcable.  Likewise 
the  severe  and  prolonged  diabetes  caused,  both  in  man  and  in  animals, 
by  the  administration,  whether  by  mouth  or  by  intravenous  injec- 
tions, of  phloridzin,  a  glucosid  extracted  from  the  bark  of  apple  trees, 
cannot  be  understood.  We  may  as  well  expect  diabetes  to  be  caused 
by  paring  the  apples  themselves.  One  fact,  however,  is  well  estab- 
lished, and  that  is,  that  each  person  has  his  own  ability  to  use 
starches  in  his  food.  Many  persons  find  that  a  marked  excess  in 
partaking  of  starchy  foods  causes  glycosuria,  but  this  varies  with  each 
individual,  for  whole  races  of  mankind,  like  the  Japanese,  live  upon 
almost  nothing  but  rice,  and  yet  they  are  no  more  subject  to  diabetes 
than  other  people.  When  glycosuria  is  caused  in  any  person  by  excess 
of  partaking  of  starchy  foods  it  is  termed  "ahmentary  glycosuria," 
and  this  is  readily  cured  by  diminishing  such  intake.  The  cHnical 
rule  is,- therefore,  universally  appHed — viz.,  to  find  out  how  much  any 
individual  may  partake  of  starchy  foods  without  sugar  appearing  in 
his  urine.  In  most  cases  this  restriction  in  itself  suffices  to  cure  the 
complaint.  In  severe  cases,  however,  as  we  have  remarked,  sugar 
still  appears,  even  though  all  carbohydrates  have  been  excluded.  The 
sugar  must  then  be  formed  from  the  protein  tissues  of  the  body  itself. 

The  so-called  alimentary  glycosuria  may  happen  in  persons  who  are 
normally  fat,  and  if  it  is  not  controlled  by  withdrawal  of  carbohydrate 


DIABETES    MELLITUS  457 

food  it  soon  yields  to  the  administration  of  from  5  to  10  gr.  of  anti- 
pyrin  with  the  same  quantity  of  sodium  saUcylate.  The  treatment  of 
diabetes  by  drugs  is  not  satisfactory,  except  in  persons  after  middle 
hfe,  as  we  shall  see.  For  a  long  time  opium  and  its  derivative  codein 
have  been  reputed  as  the  most  efi&cacious  of  drugs.  It  should  be 
undoubtedly  used  in  those  otherwise  hopeless  cases  of  diabetes  in 
young  persons.  Opium  may  be  given  at  the  beginning,  in  doses  of  i  gr. 
four  times  a  day,  gradually  increasing  until  the  patient  shows  symp- 
toms of  opium-poisoning  by  symmetric  contraction  of  the  pupils  and 
slowing  of  the  respiration.  It  is  noteworthy  that  these  patients  show 
a  great  tolerance  for  opium.  Pavy  prefers  codein  because  it  is  less 
constipating.  He  recommends  it  to  be  given  in  doses  of  ^  gr.,  three 
times  a  day,  to  be  gradually  increased  to  6  or  8  gr.  in  the  twenty-four 
hours.  As  with  all  other  drugs  in  the  treatment  of  diabetes,  no  effect 
will  be  produced  unless  the  patient  is  on  a  rigid  diet. 

Nature  does  not  cure  diabetes.  In  our  chapter  on  Remedies  we 
dwelt  upon  the  fundamental  difference  between  functional  and  con- 
stitutional remedies.  The  functional  remedies  are  those  whose  whole 
action  is  secured  by  only  one  dose.  No  matter  how  long  or  often  they 
may  be  repeated,  the  last  dose  does  not  do  anymore  than  the  first  dose 
did.  The  constitutional  remedies,  on  the  other  hand,  like  iron  in 
anemia  or  mercury  in  S5^hilis,  do  not  produce  their  effects  in  one  dose, 
but  only  after  prolonged  repetition  of  many  doses.  The  reason  for 
this  is  plain  enough,  because  constitutional  medicines  affect  the 
constitution,  so  that  it  is  not  the  same  as  it  was  before  taking  them, 
and  require  time  to  produce  the  desired  effect. 

Functional  medicines,  on  the  other  hand,  do  not  affect  the  consti- 
tution, because  the  whole  operation  has  been  in  one  dose.  On  that 
account  I  cannot  recommend  for  such  a  deep-seated  constitutional 
disease  a  merely  functional  medicine  like  opium  or  any  of  its  deriva- 
tives, Hke  codein.  A  single  poisonous  dose  of  opium  may  imperil  a 
man's  life  for  half  a  day,  but,  if  he  survives  for  twenty-four  hours, 
he  is  not  only  then  safe  from  danger,  but,  in  the  course  of  another 
day,  will  be  permanently  free  from  any  effects  of  opium,  just  as  if  he 
had  never  taken  it.  The  only  reason  that  opium  or  any  of  its  deriva- 
tives are  recommended  for  diabetes  is  that  the  percentage  of  sugar  in 
the  urine  is  temporarily  diminished  by  opium,  but  a  permanent  cure 
of  diabetes  by  this  drug  has  never  been  reported.  I  but  rarely 
prescribe  opium ;  it  can  no  more  touch  diabetes  itself  than  it  can  touch 
t5^hoid  fever,  because  it  can  never  be  anything  but  a  functional 
medicine.     Instead  of  that  for  a  number  of  years  I  have  advocated  a 


458  CLINICAL  MEDICINE 

free  use  of  cod-liver  oil  in  diabetes.  I  was  specially  led  to  do  this  by 
its  remarkable  effect  in  the  case  of  two  brothers  whom  I  treated  forty 
years  ago.  The  first,  an  active  business  man,  aged  thirty-five,  came 
to  me  with  polyuria,  thirst,  emaciation,  and  progressive  loss  of  strength, 
for  which  he  had  been  treated  unavailingly  for  a  year  with  the  usual 
course  of  diet  and  drugs,  including  opium.  He  then  took  larger  doses 
of  cod-liver  oil  than  any  patient  in  my  experience,  for  he  said  that  he 
never  measured  it,  but  took  it  directly  from  the  bottle  as  a  drink, 
followed  by  Vichy  water.  In  another  year's  time  he  was  cured,  and 
he  has  remained  well  ever  since.  His  brother,  two  years  younger,  came 
to  me  the  following  year  with  much  the  same  condition,  so  far  as  the 
great  quantity  of  sugar  in  the  urine  was  concerned.  He  found  that  he 
could  stomach  cod-liver  oil  as  well  as  his  brother. 

Next  to  cod-liver  oil  I  would  mention  iron.  As  before  remarked,  I 
have  long  suspected  diabetes  as  largely  a  muscle  disease,  and,  through- 
out the  animal  kingdom,  muscular  power  is  directly  proportioned  to 
the  intake  of  oxygen.  As  iron  can  act  in  us  only  in  the  capacity  of 
an  oxygen  carrier  I  try  to  give  diabetics  all  the  iron  which  they  can 
take,  with  all  the  fresh  air  which  they  can  get.  As  iron  in  many 
forms  tends  to  cause  constipation,  which  itself  not  infrequently  be- 
comes a  serious  trouble  to  diabetics,  a  very  serviceable  preparation  for 
them  is  the  old-fashioned  Hooper's  pill,  the  formula  of  which  is  ferrous 
sulphate,  ^  dram;  powdered  senna,  powdered  jalap,  cream  of  tartar, 
powdered  ginger,  12  gr.  of  each;  extract  of  gentian,  q.  s.;  divide  into 
30  pills;  dose,  one  pill  after  meals. 

The  next  agents  are  a  class  of  very  important  medicinal  antiseptics 
derived  from  the  coal-tar  series,  such  as  antipyrin  and  phenacetin, 
including  the  saHcylates  and  the  benzoates.  Besides  these  agents  I 
would  include  arsenic  in  this  class  of  antiseptics,  as  it  comes  nearer,  in 
its  properties  as  a  medicine,  to  such  agents  than  to  any  other.  My 
usual  practice  is  to  combine  it  in  the  same  prescription  with  them,  and, 
therefore,  I  usually  give  arsenous  acid  itself,  watching  for  the  devel- 
opment of  arsenical  symptoms,  just  as  in  prescribing  it  for  any  other 
purpose.  If  called  to  a  patient  who  is  voiding  so  large  an  amount  of 
sugar  that  a  speedy  reduction  of  it  is  imperative  I  would  give  1 5  gr.  of 
antipyrin,  with  the  same  of  sodium  benzoate,  four  times  a  day.  In  such 
acute  cases  illustrative  prescriptions  would  be  somewhat  as  follows: 

I^.     Benzosal gr.  xlviij; 

Sodium  benzoate 5iv; 

Arsenous  acid gr.  j; 

Sodium  salicylate 5iij- — M. 

Ft.  capsul.  xlviii. 
Sig. — Two  capsules  an  hour  after  meals  and  at  night. 


DIABETES    INSIPIDUS  459 

Also  a  prescription  of 

^.     Sodium  sulphocarbolate 3ij; 

Salicin 3j; 

Phenacetin 3ij; 

Ammonium  benzoate 3iv. — M. 

Ft.  capsul.  xlviii. 

Sig. — Two  capsules  one-iialf  hour  after  meals. 

If  there  be  much  insomnia,  20  gr.  of  strontium  bromid  and  15  gr.  of 
antipyrin  should  be  taken  at  night.  Lastly,  a  weekly  dose  of  blue  pill, 
followed  by  Pluto  water  or  other  laxative  water  in  the  morning,  is 
very  advisable. 

By  such  means  the  life  of  diabetics  can  unquestionably  be  much 
prolonged,  along  with  the  preservation  of  their  bodily  strength,  so 
that,  in  many  instances,  I  have  had  the  patient  continue  in  active 
business  for  years. 

DIABETES  INSIPIDUS 

This  affection  is  characterized  by  polyuria  or  an  increased  flow  of 
urine;  the  urine,  however,  is  of  low  specific  gravity  and  contains 
no  sugar.  It  may  or  may  not  contain  a  fair  amount  of  urea,  but  usu- 
ally it  is  deficient  in  all  the  soHds,  urea  included.  The  urine  may  be 
much  more  in  quantity  than  can  be  accounted  for  by  the  amount  of 
water  drunk.  I  once  had  a  patient,  in  the  case  of  a  young  man,  who 
was  at  the  time  suffering  from  great  nervous  depression,  when  he 
voided  a  very  large  quantity.  These  patients  are  often  thirsty,  but 
even  thirst  may  be  absent.  There  can  be  no  doubt  that  the  skin 
is  wholly  unable  to  absorb  any  water  as  such,  yet  quickly  absorbs 
large  quantities  of  water  when  in  the  form  of  vapor. 

Watson  mentions  the  case  of  a  jockey  at  the  Newmarket  races, 
who  had  been  starved  down  to  a  prescribed  weight  before  he  mounted 
his  horse;  the  day,  however,  was  quite  foggy,  and  he  begged  for  a  cup 
of  tea,  after  which,  on  being  weighed  again,  he  was  found  to  have 
increased  six  pounds  in  weight. 

Workers  in  glassmakers'  furnaces  have  been  known  to  lose  three 
pounds  in  weight  while  at  work,  and  then,  in  a  short  time,  recover  their 
weight  on  ceasing  work  without  meantime  drinking  a  drop. 

These  facts  should  be  remembered  before  advising  a  patient  with 
diseased  arteries  to  take  a  vapor  or  Turkish  bath.  Every  one  on  first 
entering  a  Turkish  bath  is  apt  to  feel  dizzy  from  the  effort  of  rapid 
absorption  by  the  skin  of  watery  vapor.  This  vascular  fulness  is  soon 
relieved  by  the  breaking  out  of  free  perspiration.     I  have  known, 


460  CLINICAL   MEDICINE 

however,  of  serious  injury  occurring  to  persons  with  diseased  arteries 
on  taking  a  vapor  bath. 

Cases  of  diabetes  insipidus  are  usually  cases  of  neurotic  tempera- 
ment. I  had  a  patient  at  the  Roosevelt  Hospital  who  was  admitted 
for  general  debility,  and  who  habitually  voided  no  and  more  ounces 
of  water  daily,  which  was  more  than  could  be  accounted  for  by  what 
he  drank.  I  then  put  him  upon  the  treatment  recommended  by 
Trousseau  for  this  condition,  which  was  to  administer  free  doses  of 
valerian.  This  quickly  relieved  him,  but  when  he  passed  a  normal 
quantity  of  urine  he  suddenly  developed  gangrene  of  the  lung  and  died. 

RACHITIS,   OR  RICKETS 

Rachitis,  or  rickets,  is  a  name  appHed  to  this  disease  by  the  emi- 
nent English  physician,  GHsson,  about  1650.  It  is  a  very  common 
disease  in  both  sexes,  beginning  in  infancy,  and  is  so  conunon  in  Lon- 
don and  Vienna  that  from  50  to  80  per  cent,  of  all  the  children  at  the 
clinics  present  signs  of  rickets. 

Rickets  is  a  disease  which  strikes  at  the  very  foundation  of  our 
physical  life.  We  no  longer  regard  the  bones  as  merely  the  framework 
of  the  body,  for  we  now  know  that  in  the  marrow  of  the  bones  the 
blood  itself  finds  its  origin.  A  real  fault  in  bony  development,  begin- 
ning as  rickets  usually  does  in  infancy,  for  its  presence  can  be  easily 
recognized  in  a  child  but  two  years  old,  gives  a  very  serious  outlook 
for  the  rest  of  life.  All  the  tissues  of  the  body,  therefore,  must  suffer 
more  or  less  from  general  faults  in  development  in  the  bony  structures. 
In  rickets  there  is  a  marked  deficiency  in  bony  organization,  due  to 
the  want  of  phosphate  of  lime,  which  deficiency  may  be  as  low  as  25 
or  35  per  cent.  On  this  account,  the  mere  weight  of  the  body  or  of  its 
parts  may  be  sufficient  to  cause  serious  deformities  in  their  develop- 
ment. Thus,  in  females  the  pelvis  may  be  so  changed  from  its  normal 
shape  that  the  anteroposterior  diameter  of  its  brim  may  be  reduced  to 
one-half  or  one-third  of  its  normal  length,  thus  rendering  in  after  Hfe 
parturition  difficult  or  impossible.  Meanwhile,  irregular  growths 
may  be  found  in  the  bones  of  the  head,  the  upper  part  of  the  skull 
being  so  misshapen  as  to  resemble  what  we  have  described  in  our  re- 
marks on  hydrocephalus  of  a  small  face  overhung  by  protuberant 
frontal  and  parietal  bones.  The  long  bones  of  the  extremities,  par- 
ticularly of  the  legs,  are  misshapen,  their  shafts  being  small  and  weak, 
while  their  ends  at  the  articulations  may  be  much  distorted ;  the  spine 
also  is  equally  affected,  especially  in  its  upper  part,  owing  to  the  weight 
of  the  head. 


OBESITY  46 1 

Meantime,  as  might  be  expected,  the  general  nutrition  seriously 
suffers,  the  skin  is  but  poorly  developed,  and  often  the  seat  of  super- 
ficial pains,  so  that  the  child  prefers  to  lie  in  bed,  because  every  move- 
ment of  the  body  causes  pain.  Meantime  the  abdomen  is  protuberant 
with  relative  enlargement  of  the  Hver,  spleen,  and  mesenteric  glands. 
These  children  are  late  in  their  dentition  and  slow  in  learning  to  walk, 
owing  to  the  weakness  of  their  legs. 

One,  and  by  no  means  minor,  difficulty  of  these  patients  is  from  mis- 
shapen chests,  producuig  what  is  called  the  pigeon  breast,  in  which 
the  sternum  is  not  only  too  prominent,  but  the  articulations  of  the  ribs 
are  so  irregular  that  they  form  projections  or  the  so-called  rickety 
rosary. 

Rickets  is  a  disease  of  early  childhood;  in  exceptional  cases  it  may 
develop  as  late  as  the  fourth  or  fifth  year. 

Treatment. — The  greatest  remedy  for  rickets  is  an  early  adminis- 
tration of  cod-Kver  oil,  a  remedy  well  borne  by  all  children,  who 
may  even  show  a  fondness  for  it.  Next  to  cod-Hver  oil  comes  calcium 
lactate,  which  maybe  given  in  10-  or  even  15-gr.  doses  four  times  a 
day  with  milk. 

SCLERODERMA 

This  is  an  affection  of  the  skin  in  which  its  tissue  becomes 
much  thickened.  It  is  very  irregular  in  its  distribution,  its  most 
common  sites  being  about  the  neck.  It  cannot  be  called  an  inflam- 
mation of  the  skin,  as  it  has  no  relation  to  any  of  the  forms  of  derma- 
titis. A  local  development  of  this  trouble  is  sometimes  seen  in  which 
the  growth  of  the  nails  becomes  very  distorted.  When  it  affects  the 
hands  it  stiffens  them  so  as  to  make  writing  and  movements  of  the 
fingers  difl&cult.  Occasionally,  the  parts  affected  become  deeply 
pigmented. 

Treatment. — ^Very  favorable  results  in  its  treatment  have  been  re- 
ported by  the  administration  of  thyroid  tablets  in  3-  to  5-gr.  doses, 
three  or  four  times  daily;  otherwise  it  seems  not  to  be  amenable  to  any 
of  the  remedies  for  cutaneous  diseases. 

OBESITY 

Physicians  are  often  consulted,  particularly  by  women,  for  advice 
for  reducing  fat.  Such  cases  require,  first,  a  careful  investigation 
into  the  daily  habits  of  the  patient.  In  many  cases  the  tendency  to 
increase  in  bodily  weight  from  deposition  of  fat  is  a  hereditary  com- 
plaint, but  it  is  often  conjoined  with  an  abnormal  appetite,  and  can 
be  treated  by  cutting  down  the  intake  of  starches  and  of  sweets. 


462  CLINICAL  MEDICINE 

I  those  who  can  afford  it  a  prolonged  horseback  ride  over  high  and 
dry  plains  proves  very  efficacious,  by  not  only  reducing  the  fat,  but  by 
greatly  increasing  the  physical  vigor  of  the  patient.  In  some  cases 
there  can  be  no  doubt  that  obesity  is  due  to  perversion  of  the 
hypophysis  or  pituitary  gland,  which  is  characterized  by  a  great 
increase  in  fat  in  early  life  and  by  infantilism  in  the  sexual  glands. 

Treatment. — We  have  only  one  agent  which  directly  lessens  the 
fat  in  the  body,  and  that  is,  extract  of  the  thyroid  gland.  We  might 
infer  that  the  thyroid  has  the  property  of  reducing  fat  from  the  com- 
mon supervention  of  emaciation  in  Graves'  disease.  I  once  had  a 
patient  with  Graves'  disease  in  which  I  was  obliged  to  pad  the  patient 
with  cotton  batting  to  prevent  the  bones  from  cutting  through  the 
skin ;  on  curing  her  of  Graves'  disease  she  became  perfectly  normal  in 
the  restoration  of  the  subcutaneous  cushion  of  fat,  which,  in  health, 
preserves  the  nerves  from  being  pressed  upon  by  the  bones,  as  described 
in  our  chapter  on  Emaciation. 

The  administration  of  thyroid  tablets  should  not,  at  the  begin- 
ning, be  left  to  the  discretion  of  the  patient,  but  they  should  be  given 
by  a  trained  nurse,  for  it  would  be  easy  for  the  patient  to  exceed  the 
proper  dose  of  these  tablets,  with  the  production  of  tachycardia  and 
much  general  debility.  The  dose  should  be,  at  first,  not  more  than  3- 
gr.  tablets,  gradually  increasing  to  5-gr.  tablets,  three  times  a  day. 

FATTY  TUMORS 

Fatty  tumors  will  be  considered  later,  under  the  head  of  New 
Growths.  There  is  one  variety,  however,  called  adiposis  dolorosa, 
or  Dercum's  disease,  characterized  by  fatty  deposits  under  the  skin 
which  are  painful  to  pressure.  The  etiology  of  these  cases  is  obscure, 
and  they  are  best  treated  by  local  applications  of  anodyne  Hniments, 
such  as  camphorated  oil,  i  oz.;  tincture  of  opium;  2  drams,  and 
menthol,  i  dram. 

It  may  be  well  here  to  allude  to  hysteric  tumors.  These  are  often 
definitely  circumscribed,  tumor-like  swellings  on  the  surface  of  the 
abdomen.  I  once  heard  a  well-known  gynecologist  begin  a  lecture  on 
ovarian  cysts  previous  to  his  operating  upon  the  tumor,  but  when  the 
patient  was  passing  under  an  anesthetic  the  tumor  entirely  disap- 
peared. 


CHAPTER  XII 
DISEASES  OF  THE  DUCTLESS  GLANDS 

INTRODUCTION 

The  ductless  glands  are  so-called  from  their  secretions  being  dis- 
charged directly  into  the  blood  instead  of  flowing  through  ducts  pro- 
ceeding from  them.  As  their  secretions,  therefore,  cannot  be  collected 
for  examination,  we  know  little  about  them,  except  by  noting  the 
effects  of  their  absence  in  cases  of  excision  or  atrophy. 

The  ductless  glands  vary  greatly  in  size  between  themselves,  from 
the  thyroid,  which  may  weigh  from  500  to  1000  gr.,  to  the  pituitary 
gland,  which  weighs  only  5  gr.  But  the  importance  of  their  functions 
bears  no  relation  to  their  size  or  weight.  They  are  all  about  equally 
necessary  at  some  time  to  the  nutrition  and  hfe  of  the  body,  though 
their  importance  varies  much  with  age.  Thus,  the  thymus  passes 
out  of  commission  at  an  early  period.  The  thyroid  also  is  a  temporary 
organ  that  atrophies  in  old  age,  which,  if  experimentally  removed,  is 
quickly  fatal  to  young  dogs,  while  old  dogs  are  but  Httle  affected  by  this 
operation,  and  its  importance,  though  great,  is  chiefly  concerned  with 
the  reproductive  period  of  Hfe. 

No  organ  of  the  body  is  so  often  hypertrophied  as  the  thyroid, 
forming  then  what  are  called  goiters.  These  vary  greatly  in  their 
causation.  A  larger  class  of  them  are  caused  by  something  in  the 
water  drunk,  it  may  be  in  very  restricted  locahties.  Thus,  Lombroso 
and  other  Italian  writers  speak  of  goitrous  wells,  the  drinking-water 
of  which  is  resorted  to  for  the  purpose  of  developing  goiters  so  as  to 
exempt  the  men  from  military  service.  The  waters  of  these  wells  also 
cause  goiters  in  dogs  and  in  horses. 

Endemic  goiters  occur  in  all  parts  of  the  world.  In  England  we 
read  of  the  Derbyshire  neck,  and  this  affection  is  very  prevalent  in 
valleys  in  Switzerland  and  in  the  Pyrennees.  It  is  not,  however,  by 
any  means  limited  to  mountainous  districts,  for  it  may  be  equally 
prevalent  in  plain  or  flat  regions.  For  a  long  time  it  was  supposed 
that  waters  containing  lime  or  magnesiimi  salts  were  the  cause  of 
endemic  goiters  and  also  of  the  prevalence  of  cretinism,  but  this  hypoth- 
esis is  now  abandoned.     One  of  the  most  instructive  investigations 

463 


464  CLINICAL  MEDICINE 

on  this  subject  was  made  by  Dr.  Robert  McCarrison,  a  British  sur- 
geon in  India,  who  observed  endemic  goiter  in  a  number  of  locaHties 
in  Gilgit  and  Chitral,  in  the  Himalaya  regions,  recorded  in  the  Milroy 
lectures  of  191 2.  He  conclusively  demonstrates  that  the  infected 
waters  are  not  so  on  account  of  any  geologic  formation,  and  concludes 
that  the  disorder  is  due  to  a  Uving  growth,  but  whether  bacterial  or 
protozoal  has  not  yet  been  demonstrated.  It  passes  through  the 
pores  of  a  Berkefeld  filter,  and  seems  to  be  highly  resistant  to  heat,  re- 
quiring at  least  70°  C.  to  render  the  water  innocuous.  One  of  the 
most  striking  diseases  is  due  to  atrophy  of  the  thyroid  gland,  causing 
the  disease  first  described  by  Sir  William  Gull,  but  which  goes  by  the 
name  myxedema,  given  to  it  by  Dr.  Ord.  In  former  times  this  disease 
was  produced  by  surgical  operations,  in  which  the  whole  thyroid  gland 
was  removed  by  Dr.  Kocher,  of  Bern,  Switzerland,  but  it  was  not 
until  this  operation  was  shown  to  be  the  actual  cause,  of  myxedema 
that  it  was  abandoned.  Myxedema,  however,  sometimes  seems  to 
occur  spontaneously,  but  in  every  case  when  the  complaint  ended 
fatally,  autopsy  showed  complete  atrophy  of  the  thyroid  gland.  The 
symptoms  of  myxedema  are  first  a  gradual  failure  of  strength,  then  a 
slowness  of  speech  with  duhiess  of  the  mind.  CUnically,  however, 
the  symptoms  are  very  distinct,  and  consist  of  general  puffiness  of  the 
face,  beginning  with  the  eyelids,  with  thickening  of  the  lips  and  of  the 
alae  nasi,  and  extending  until  the  whole  face  looks  broad,  without  ex- 
pression, and  the  hands  enlarged,  with  fingers  becoming  so  thickened 
that  the  hand  has  a  spade-like  appearance.  Meantime  the  subcu- 
taneous tissues  are  infiltrated  with  a  mucin-like  fluid,  which  is  not  true 
edema,  for  the  skin  does  not  pit  on  pressure.  This  is  early  developed 
in  the  neck,  especially  about  the  clavicles.  The  patients  become  very 
sluggish  in  their  movements,  and  complain  greatly  of  the  cold,  their 
temperatures  sometimes  falling  to  95°  F.,  and  death  occurs  from  heart 
failure. 

That  this  affection  is  due  solely  to  atrophy  of  the  thyroid  gland  is 
shown  by  the  remarkable  efficacy,  particularly  demonstrated  by  Dr. 
Hector  MacKenzie,  of  the  administration  of  extracts  of  the  thyroid 
gland  of  sheep.  This  is  now  sold  in  compressed  tablets,  usually  of 
5  gr.  each,  and  may  be  taken  by  such  patients,  one  three  times  a  day, 
to  be  afterward  diminished,  according  to  the  improvement  of  the 
patient,  to  only  one  a  day,  or  even  one  a  week.  Overdosing  with 
thyroid  tablets  produces  nervousness  and  rapid  action  of  the  heart, 
which  symptoms  soon  cease  on  diminishing  the  dose,  and  it  is  undeni- 
able that  all  of  the  serious  symptoms  of  myxedema  are  surely  cured 


,     DISEASES    OF   THE    THYMUS    GLAND  465 

by  thus  supplying  artificially  the  normal  secretion  of  the  thyroid 
gland. 

The  thyroid  gland,  like  the  pancreas,  is  a  compound  organ,  because 
embedded  in  its  substance  are  small  bodies,  distinct  from  it  in  function, 
called  the  parathyroids,  usually  four  in  number,  two  on  each  side  of 
the  gland.  Halsted  and  MacCallom  have  demonstrated  that  they  are 
necessary  for  life,  because  their  experimental  removal  in  animals  has 
been  followed  by  fatal  tetanus.  In  milder  degrees,  twitching  and 
cramps  of  the  muscles,  usually  those  of  the  extremities,  take  place,  to 
which  the  term  "tetany"  has  been  given.  MacCallom  has  shown 
that  these  bodies  bear  an  important  relation  to  the  presence  of  calcium 
in  nutrition,  especially  of  the  nervous  system,  and  recommends  the 
administration  of  calcium  lactate  for  affections  caused  apparently  by 
deficiency  in  parathyroid  secretion.  Besides  tetanoid  cramp,  the 
animals  experimented  upon  developed  general  muscular  tremors, 
which  were  noted  as  results  of  complete  thyroidectomy,  before  the 
presence  of  the  parathyroids  was  known.  It  is  not  improbable  that 
the  tremors  so  generally  present  in  Graves'  disease  are  due,  in  part  at 
least,  to  implication  of  the  parathyroids.  It  is  now  generally  admitted 
that  the  morbid  condition  termed  "tetany"  is  connected  with  implica- 
tion of  the  parathyroids.  In  this  country  tetany  occurs  chiefly  among 
children,  and  consists  of  spasmodic  contractions  of  the  muscles  of  the 
different  parts,  but  chiefly  of  the  extremities.  It  may  last  from  a  few 
hours  to  several  weeks.  In  my  experience  it  occurs  oftenest  in  chil- 
dren with  gastric  intestinal  disorders,  particularly  diarrhea.  It  is 
best  treated  by  the  administration  of  15  gr.  of  calcium  lactate,  four 
times  a  day.     Some  do  well  simply  with  doses  of  thyroid  extract. 

DISEASES  OF  THE  THYMUS  GLAND 

The  thymus  is  a  ductless  gland  whose  functions  are  very  obscure. 
Its  entire  removal  without  injury  to  the  general  health  has  been  suc- 
cessfully performed  in  a  number  of  instances.  Owing  to  its  position, 
the  th3nTLUS  may  produce  difficulty  in  breathing  by  compression  of  the 
trachea.  Sudden  death  in  infants  has  been  often  reported  and  ascribed 
to  disorders  of  the  thymus  gland  without  any  clear  reasons  being  ad- 
duced for  the  fatal  event.  We  have,  therefore,  to  deduce  our  conclu- 
sions about  the  relations  of  this  gland,  namely,  from  its  apparent  con- 
nection with  the  lymphatic  system.  I  once  thought  it  probable  to 
suppose  that  it  had  close  connection  with  the  origin  of  the  white  cor- 
puscles of  the  blood,  because  disorders  of  the  lymphatic  system  are 
so  often  accompanied  by  enlargement  of  the  thymus. 


466  CLINICAL  MEDICINE 

The  thymus  is,  Hke  the  thyroid,  a  temporary  body,  and  atrophies 
with  advancing  years.  Thus,  as  we  have  stated  in  our  article  on 
Graves'  Disease,  extirpation  of  the  thyroid  is  quickly  fatal  in  young 
dogs,  while  old  dogs  bear  this  excision  very  well,  showing  that  the 
thyroid  is  related  closely  to  the  reproductive  period  of  life.  Similarly, 
the  thymus  is  a  temporary  gland,  and  after  twenty-five  years  it  gradu- 
ally atrophies.  We  hear,  therefore,  of  persistent  thymus,  as  associ- 
ated with  diseases  of  the  lymphatic  system,  but  no  disorders  of  this 
gland  have  yet  been  identified  with  any  distinct  derangement  of  other 
organs.  In  all  conditions  of  so-called  lymphatism  the  heart  is  found 
weak,  and,  therefore,  the  administration  of  either  chloroform  or  ether 
is  contra-indicated. 

The  so-called  status  lymphaticus  is  characterized  by  weakness  of  the 
heart  and  of  the  arteries  in  general.  The  patients  are  usually  sluggish, 
easily  fatigued,  and  have  a  yellowish  pasty  complexion,  in  all  of  whom 
the  thymus  is  often  reported  as  persistent,  when  naturally  it  ought  to 
have  entered  upon  its  retrogressive  changes. 

Attacks  of  labored  breathing  with  stridor  have  been  reported  as 
due  to  hypertrophy  of  the  thymus  gland  pressing  from  its  position  upon 
the  trachea,  but  there  is  a  divergence  of  opinion  among  authors  on  the 
connection  of  these  attacks  with  hypertrophy  of  the  thymus,  because 
such  attacks  frequently  occur  in  spasmodic  croup  without  any  relation 
to  conditions  of  this  gland. 

DISEASE  OF  THE  PITUITARY  GLAND;  ACROMEGALY 

The  pituitary  gland  is  located  in  the  most  inaccessible  part  of  the 
skull,  called  the  "sella  turcica"  or  Turkish  saddle,  which  is  a  remark- 
able depression  in  the  sphenoid  bone.  This  gland  is  also  called  the 
"hypophysis,"  and  weighs  only  5  gr.  It  is  comprised  chiefly  of  two 
parts,  the  anterior  lobe,  which  is  larger,  and  the  posterior  lobe,  called 
the  pars  nervosa,  connected  by  an  intermediate  portion,  the  infundibu- 
lum.  It  must  be  a  body  of  primary  importance,  because  its  excision 
is  invariably  and  quickly  fatal.  Moreover,  disease  of  the  pituitary 
gland  is  accompanied  by  very  striking  change  in  the  growth  and  nutri- 
tion of  the  body,  producing  great  hypertrophy  of  the  hands  and  feet, 
which  are  much  enlarged,  though  not  deformed. 

We  have  already  alluded  to  the  remarkable  association  of  the  duct- 
less glands  with  each  other  in  their  functions,  so  that  in  cases  of 
enlargement  of  the  thyroid  we  often  find  hypertrophy  of  the  pituitary 
also  occurring,  while  the  pituitary,  the  pancreas,  and  the  adrenals 
appear  to  be  simultaneously  affected  in  some  conditions  of  glycosuria. 


THE  adrenals:  addision's  disease-  467 

It  is  to  Harvey  Gushing,  of  Johns  Hopkins  University,  that  the  most 
recent  advances  in  the  knowledge  of  the  pituitary  gland's  functions 
have  been  made.  He  has  shown  that  tumors,  like  adenomata  growing 
in  the  neighborhood  of  the  pituitary  gland,  may  either  occasion  by 
their  stimulation  an  increase  in  the  growth  of  bones,  such  as  gigantism, 
as  the  first  step  toward  the  development  of  acromegaly,  or,  when  such 
growths  have  caused  atrophy  of  the  pituitary  gland,  and  thus  inter- 
fered with  its  functions,  that  the  opposite  effect  of  dwarfism  and  a 
reversion  to  infantile  development  of  the  generative  organs  may  occur, 
with  a  marked  tendency  to  increase  of  fat  in  the  body. 

Coincident  with  the  increase  of  fat  and  infantilism  there  is  a  notable 
increase  in  the  power  of  the  body  to  assimilate  the  carbohydrates. 

The  physical  features  of  acromegaly  are  very  striking.  "The 
skull  increases  in  volume,  but  not  so  much  in  proportion  as  the  face, 
which  becomes  elongated  and  enlarges  in  consequence  of  the  increase 
in  the  size  of  the  superior  and  inferior  maxillary  bones"  (Osier). 
The  latter  particularly  increases  in  size,  and  often  projects  below  the 
upper  jaw.  The  external  ears  may  also  be  much  enlarged.  Meantime 
the  bones  of  the  extremities  become  both  enlarged  and  elongated,  with 
hypertrophy  of  their  cartilages.  All  features  contributing  to  gigan- 
tism are  associated  with  acromegaly.  It  has  long  been  noted  in  the 
bodies  of  giants  that  the  sella  turcica  is  much  hyper trophied. 

Treatment  appears  to  be  of  no  avail  in  this  remarkable  complaint. 
Extracts  made  of  the  posterior  lobe  of  the  pituitary  raise  the  blood- 
pressure  and  act  as  diuretics,  not  unUke  the  action  of  digitaHs. 

THE  ADRENALS:  ADDISON'S  DISEASE 
A  great  deal  of  work  has  been  expended  upon  the  origin  and  func- 
tions of  those  two  ductless  glands,  which  are  called  the  adrenals,  from 
their  situation  on  the  top,  but  which  have  no  anatomic  connection 
with  the  kidneys  underneath.  The  origin  of  an  adrenal  gland  is 
directly  traced  to  a  branch  of  the  abdominal  sympathetic,  which 
becomes  rolled  upon  itself  like  a  ball  of  twine,  and  then,  separating 
from  its  attachment,  it  takes  a  capsule,  and  thus  forms  an  adrenal 
gland.  These  adrenal  glands  are  more  directly  necessary  to  life  than 
the  kidneys  themselves,  for  animals  more  quickly  succumb  to  the 
effects  of  their  excisions  than  when  the  kidneys  are  removed. 

The  function  of  the  internal  secretion  of  the  adrenals  is  shown  to 
consist  in  the  maintenance  of  the  excitabihty  and  tone  of  the  vasomotor 
nerves  throughout  the  body,  because,  after  excision  of  the  adrenals, 
stimulation  of  the  vasomotor  nerves  no  longer  causes  the  arteries  either 


468  CLINICAL   MEDICINE 

to  actively  contract  or  to  dilate.  This  is  all  due  to  the  presence  in  the 
secretion  of  a  powerful  agent  called  adrenaHn,  which  is  now  isolated 
from  the  secretion,  and  is  the  only  example,  so  far  known,  of  an  actual 
drug  being  formed  by  a  gland  which  is  sold  hke  any  other  drug  over 
the  counter. 

The  properties  of  adrenalin  are  very  distinct,  and  consist  of  im- 
mediately raising  the  blood-pressure  through  active  contraction  of  the 
arterial  walls.  Due  to  its  contracting  the  arteries,  adrenalin  has  many 
uses,  such  as  by  local  application  to  arrest  hemorrhage  or  to  produce 
arterial  anemia  in  part.  It  may  also  be  owing  to  excess  of  adrenalin 
in  the  blood  that  atheroma  occurs  in  the  coats  of  large  arteries,  for 
such  results  have  followed  experimental  administration  of  adrenaHn 
in  the  coats  of  the  aorta  in  rabbits. 

Addison's  disease  derived  its  name  from  the  eminent  English  phys- 
ician of  Guy's  Hospital,  who  first  described  it  in  1835.  His  attention 
was  first  directed  to  it  by  a  remarkable  discoloration  of  the  skin  which 
ordinarily  accompanies  this  complaint.  This  discoloration  is  very  vari- 
able, both  in  its  situation  and  extent,  ordinarily  appearing  first,  on  the 
sides  of  the  neck,  and  extending  thence,  with  deepening  of  its  shades, 
to  the  axilla  and  other  parts,  where  the  skin  may  be  folded  on  itself, 
becoming,  as  it  deepens  in  tint,  like  the  color  of  bronze.  In  other  cases 
it  appears  first  on  the  inside  of  the  lips  and  in  the  buccal  cavity.  I 
have  known  it,  however,  to  be  found  only  scattered  along  the  processes 
of  the  spine. 

Addison  then  found  that  this  discoloration  was  accompanied  by 
disease  of  the  adrenal  glands  themselves,  commonly  due  to  tubercu- 
losis, either  destrojdng  the  gland  or  implicating  the  adjoining  tissues, 
especially  when  that  great  center  of  the  abdominal  sympathetic,  the 
solar  plexus,  was  involved,  from  which,  as  we  have  seen,  the  adrenals 
take  their  origin.  The  disease^  however,  does  not  depend  upon  tuber- 
culosis, because  the  same  results  follow  if  the  adrenals  are  invaded  by 
cancer. 

Symptoms. — As  might  be  expected  from  a  disease  which  involves 
so  generally  the  abdominal  sympathetic,  various  digestive  disturbances 
occur  early  in  the  course  of  this  disease,  such  as  abdominal  pains,  re- 
ferred to  the  alimentary  canal,  and  disturbances  of  the  stomach  and 
bowels.  But  the  most  constant  accompaniment  is  general  muscular 
weakness  and  debility,  ultimately,  if  not  checked,  leading  to  death 
from  pure  asthenia,  not  at  all  due  to  changes  in  the  blood  nor  in  general 
nutrition,  for  the  blood  remains  nearly  normal,  and  the  patients  do  not 
lose  flesh  or  color. 


THE  thyroid:  cretinism  469 

No  treatment  for  this  complaint  was  known  until  the  deficiency 
was  supplied  by  the  administration  of  tablets  made  from  the  adrenal 
glands  of  sheep. 

I  had  a  patient  come  to  me  with  unmistakable  symptoms  of  Addi- 
son's disease,  including  bronzing  of  the  skin  of  the  neck.  He  was  a 
well-to-do  farmer  in  the  western  part  of  New  York  state,  and  I  put 
him  at  once  upon  tablets  of  the  extract  of  the  adrenal  glands,  put  up 
by  Burroughs,  Wellcome  &  Co.,  of  London.  He  rapidly  improved 
under  their  administration,  and  was  enabled  to  resume  his  business,  his 
skin  wholly  clearing  up.  But  one  singular  result  was  that  he  had 
been  married  for  ten  years  without  having  any  children,  while  after 
taking  the  tablets  he  informed  me  that  his  wife  bore  two  boys,  one 
of  whom,  at  last  accounts,  was  going  to  college.  He,  however,  has  to 
take  his  tablets  continuously,  for  so  soon  as  he  omits  them  all  the 
S3rmptoms  of  his  complaint  begin  to  reappear. 

Addison's  disease  is  not  at  all  common  in  the  United  States.  I 
have  seen  only  3  cases  of  it  in  private  practice,  but  it  is  so  peculiar 
and  unmistakable  in  its  symptoms  that  its  diagnosis  is  not  difficult. 

THE   THYROID:  CRETINISM 

This  morbid  condition  appears  in  children,  in  some  cases  from  birth, 
though  usually  not  until  the  end  of  the  first  year,  when  it  may  be  noted 
that  the  child  seems  backward  both  in  growth  and  in  mind.  Occa- 
sionally, all  goes  well  for  the  first  few  years,  when  it  ceases  to  develop, 
its  features  alter,  and  it  becomes  dull  and  stupid.  As  it  becomes  older 
it  looks  dwarfed  and  stunted,  and  Hector  MacKenzie  adds  the  follow- 
ing graphic  description: 

*'A  disproportionately  large  head,  a  short,  deformed  body,  with 
thick  arms  and  crooked  legs.  The  head  is  flat  at  the  top,  narrow  in 
front,  and  broad  behind.  The  face  also  is  broad,  but  without  expres- 
sion, and  often  wrinkled,  as  in  the  aged,  with  a  pale  waxy  complexion. 
The  eyes  have  swollen  lids  and  are  wide  apart;  the  nose  is  broad,  de- 
pressed at  the  root,  and  the  nostrils  widely  opened,  as  in  the  negro. 
The  cheeks  below  the  prominent  malar  processes  are  loose  and  flabby. 
The  ears  are  large  and  thick  and  the  lips  negroid,  with  the  mouth  open 
and  drooling.  The  lower  jaw  is  thick  and  broad,  the  neck  short  and 
thick,  and  may  have  large  fatty  masses  both  felt  and  seen  above  the 
clavicles.  The  head  often  hangs  forward  on  the  chest,  the  erector 
muscles  being  too  weak  to  support  its  weight;  this  produces  a  curva- 
ture of  the  cervical  and  upper  dorsal  spine.  The  breast  is  strikingly 
flat,  and  the  chest  is  round  and  expanded  at  the  base,  while  the  costal 


47©  CLINICAL  MEDICINE 

angle  is  wide.  There  is  usually  bowing  of  the  lower  dorsal  and  lumbar 
spine,  and  the  abdomen  is  characteristically  large,  protuberant,  and 
pendulous.  There  is  frequently  an  umbilical  hernia.  The  hips  are 
small  and  the  limbs  are  short  and  thick.  The  hands  are  broad,  short, 
and  podgy,  and  their  skin  is  thick,  especially  on  the  dorsum,  and 
wrinkled.  The  legs  are  often  bowed,  the  ankles  are  enlarged,  and  the 
feet  are  thick  and  square.  The  nails  are  short,  thickened,  cracked  or 
chinky,  and  ill-shaped.  The  skin  is  yellowish  white,  dry,  branny,  and 
rough  to  the  touch.  It  feels  doughy  from  the  thickening  of  the  subcu- 
taneous tissues,  is  loose,  and  hangs  in  folds  over  the  abdomen  and  at 
the  flexures  of  the  joints.  Sweating  is  exceptional,  but  absence  of 
perspiration  is  not  so  constant  as  in  myxedema.  Moles  or  pigment 
spots  or  patches  of  a  yellowish  or  brown  color  or  warts  are  not  uncom- 
mon on  various  parts  of  the  body.  The  hair  is  short  and  scanty,  and 
is  coarse,  dry,  straight,  and  sometimes  bristly,  more  like  horsehair  than 
that  of  the  human  being.  In  adult  cretins  it  is  usually  absent  on  the 
body.  The  eyebrows  are  often  scanty,  but  may  be  well  formed.  The 
scalp  is  dry  and  scurfy,  and  is  sometimes  covered  with  yellowish  or 
brownish  crusts.  The  teeth  are  late  in  appearing  and  soon  become 
carious.  In  sporadic  cases  there  is  usually  no  evidence  of  the  presence 
of  the  thyroid  gland,  but  there  may  be  enlargement  of  the  gland  or  a 
goiter,  and  this  is  common  in  the  endemic  cases.  The  temperature  is 
subnormal;  the  child  is  always  cold,  Hkes  to  be  near  the  fire,  and  is 
very  sensitive  to  any  fall  in  the  thermometer.  In  cold  weather  the 
exposed  parts  of  the  body  become  blue.  The  bowels  are  frequently 
obstinately  constipated  and  the  breath  has  a  disagreeable  odor.  The 
urine  is  usually  large  in  amount,  but  is  otherwise  normal.  There  is 
generally  control  over  the  sphincters,  and  when  there  is  sufHcient 
degree  of  intelligence  the  patients  are  cleanly  in  their  habits.  The 
blood  shows  little  change  in  corpuscular  elements,  but  there  is  usually 
deficiency  in  the  amount  of  hemoglobin,  which  may  be  no  more  than 
50  or  even  40  per  cent,  of  the  normal.  In  some  cases  there  has  been  a 
tendency  to  hemorrhages,  especially  from  the  nose.  The  intellectual 
condition  of  the  cretin  is  always  extremely  low.  The  mental  capacity 
varies  from  that  of  a  low-grade  idiot,  on  the  one  hand,  to  that  of  a  child 
of  four  or  five  years  old,  when  the  cretin  is  grown  up,  so  to  speak.  The 
cretin  does  not  learn  to  talk  or  to  walk  at  the  usual  time,  and  does  not 
attempt  to  move  about  like  an  ordinary  healthy  child.  Sometimes,  so 
far  from  learning  to  walk,  it  remains  unable  to  stand  or  sit  unless 
propped  up  and  supported.  In  other  cases  it  may  only  be  able  to  move 
about  by  crawling  on  all  fours.     Eventually,  however,  the  power  of 


THE   THYROID:    CRETINISM  47 1 

walking  may  be  acquired,  but  the  gait  is  waddling  and  clumsy.  The 
power  of  speech  sometimes  remains  altogether  undeveloped.  Some- 
times the  cretin  cannot  even  cry  or  scream  like  an  ordinary  child,  and 
expresses  pleasure,  anger,  or  fear  by  means  of  inarticulate  grunts, 
howls  or  shrieks,  barks,  or  groans  only.  In  course  of  time  it  may  learn 
to  say  a  few  words,  such  as  'yes,'  'no,'  'mamma,'  or  'pussy,'  and  it 
may  learn  to  understand  a  little  when  spoken  to.  It  may  also  leam 
the  signification  of  gestures.  A  small  number  acquire  a  more  extensive 
vocabulary,  which  is,  however,  very  much  restricted,  and  is  composed 
almost  entirely  of  monosyllables.  Many  of  the  consonants  are  very 
imperfectly  pronounced.  The  voice  is  often  harsh  and  hoarse.  The 
cretin  is  usually  dull  of  hearing;  the  degree  of  deafness  is  generally 
proportional  to  the  stage  of  the  disease.  The  deafness  accounts  for 
some  of  the  mental  dulness,  and,  to  some  extent,  for  the  inaptitude 
of  speech.  Smell  and  taste  are  usually  imperfect.  Cretins  often  ap- 
pear insensible  to  bad  odors,  and  indifferent  whether  food  is  palatable 
or  not.  Sight  is  one  of  the  senses  the  least  affected.  Usually  it  is 
normal,  but  the  retina  does  not  seem  so  sensitive  to  strong  or  dazzling 
light  as  in  ordinary  persons.  The  cretin  has  been  observed  to  sit 
with  the  sun  full  in  his  eyes  for  a  long  time. 

"In  adult  cretins  the  genital  organs  remain  those  of  a  child.  There 
is  absence  of  hair  over  the  pubes,  the  axilla,  and  elsewhere  on  the 
body,  and  hair  does  not  appear  on  the  face  in  males.  Males  have  a 
diminutive  penis  and  small  testicles,  and  females  have  the  labia  of 
little  girls  and  an  infantile  uterus.  The  catamenia  are  absent  or  ir- 
regular, and  sexual  instinct  is,  as  a  rule,  undeveloped.  In  high-grade 
cretins  there  may,  however,  be  some  evidence  of  development  of  sexual 
appetite  and  instinct. 

"The  cretins  are  usually  good-natured  and  placid,  and,  although 
stolid,  are  easily  amused.  It  is  sometimes  difficult  to  attract  their 
attention  by  appealing  either  to  the  sense  of  hearing  or  sight.  They 
are  apathetic  and  phlegmatic,  and  very  slow  and  deliberate  in  all  their 
movements.  They  are  somnolent,  and  will  sometimes  sleep  almost 
indefinitely  if  undisturbed.  During  sleep  they  breathe  noisily. 
When  awake  they  are  lazy  and  inert.  They  will  remain  in  the  same 
position,  and  play  for  hours  without  moving  or  taking  any  apparent 
interest  in  surroundings;  one  cretin  will  take  a  full  minute  to  raise  her 
arm  when  asked  to  shake  hands." 

Treatment. — Such  is  a  good  description  before  modern  medicine 
discovered  how  to  heal  this  wretched  disorder.  In  the  Middle  Ages 
they  suffered  from  barbarous  enactments  designed  to  rid  the  com- 


472  CLINICAL  MEDICINE 

munity  of  their  presence.  This  was  but  a  reversion  to  the  habit  of 
animals  putting  to  death  wounded  or  disabled  fellow  animals.  It  is 
one  of  the  brightest  discoveries  of  modern  medicine  that  cretinism  is 
due  to  the  absence  or  failure  of  the  functions  of  the  thyroid  gland.  In 
many  cretins  postmortem  examination  shows  little  or  no  trace  of  the 
thyroid  existing.  In  1891  Prof.  George  Murray  showed  how  myx- 
edema could  be  cured  by  the  administration  of  the  thyroid  gland  of 
sheep,  and  shortly  afterward  it  was  discovered  by  Dr.  Hector  Mac- 
Kenzie,  Dr.  E.  L.  Fox,  of  Plymouth,  and  by  Howitz,  of  Copenhagen, 
independently,  that  administration  of  sheep's  thyroid  by  the  mouth  was 
as  effective  as  by  any  other  method  for  curing  the  disease.  If  taken 
early  enough,  this  treatment  restores  the  bodily  growth  and  the  mental 
abihty  of  these  previously  unfortunate  patients,  so  that  they  are  not 
inferior  in  their  physical  and  mental  development  to  others  of  the  same 
age.  This  treatment,  however,  should  be  undertaken  early  to  show 
its  best  effects,  but  even  in  adolescence,  cure,  if  not  at  least  marked 
improvement,  in  all  respects  occurs.  The  best  preparations  are  the 
thyroid  tablets,  put  up  by  Messrs.  Burroughs,  Wellcome  &  Co.,  of  Lon- 
don. The  dose  which  has  to  be  given  varies  in  amount.  In  com- 
mencing treatment  we  must  feel  our  way.  If  too  large  a  dose  be  given, 
great  constitutional  disturbance  may  be  produced.  Even  a  dose  of  5  gr. 
has  made  a  patient  feel  ill,  causing  fever,  excitement,  depression,  and 
general  pains  in  the  body  and  limbs.  A  small  dose,  i  gr.  of  the  thyroid 
tablet  or  i  minim  of  liquor  thyroidei,  is  sufficient  to  start  with,  and  this 
should  be  cautiously  repeated  at  short  intervals,  treatment  being  sus- 
pended when  any  undesirable  symptoms  are  observed.  In  i  case  a 
dose  of  1 1  gr.,  given  every  third  day,  has  sufficed  to  cure  the  patient 
and  afterward  to  keep  him  well.  In  another,  gradually  increasing 
doses,  up  to  3  gr.  a  day,  were  found  necessary.  Sometimes  as  much  as 
ID  gr.  daily  has  been  required,  and  a  smaller  dose  has  not  sufficed.  In 
one  of  my  patients  a  dose  of  10  gr.  a  day  has  now  been  taken  for  the  past 
twelve  years.  Probably  5  gr.  a  day  may  be  considered  as  an  average 
dose  necessary  to  keep  the  patient  well  when  the  symptoms  of  the 
disease  have  all  disappeared.  As  in  the  case  of  myxedema,  the  remedy 
must  be  regularly  taken  during  the  whole  of  the  patient's  life.  Should 
the  remedy  be  suspended,  myxedematous  symptoms  gradually  reap- 
pear. One  of  the  most  remarkable  effects  of  the  treatment  is  that  the 
growth  which  has  been  so  completely  arrested  almost  immediately 
recommences,  and  it  is  not  unusual  for  a  young  cretin  to  grow  several 
inches  in  six  months. 

There  could  scarcely  be  a  more  impressive  illustration  on  the 


graves'  diseases  473 

importance  of  the  thyroid  gland  to  all  bodily  nutrition  than   that 
which  cretinism  furnishes. 

GRAVES'  DISEASE 

Graves'  disease  has  attracted  a  great  deal  of  attention  on  the  part 
of  the  medical  profession.  Kocher  pubUshed,  in  1903,  a  bibliography 
of  this  disease  at  that  time,  and  it  amounted  to  1400  treatises  or  papers 
on  the  disease,  and  since  then  the  accumulation  of  such  written  refer- 
ences to  it  has  been  even  more  remarkable. 

Symptoms. — It  is  always  unfortunate  for  a  disease  to  be  named  after 
any  of  its  prominent  symptoms,  because  it  may  happen  that  those 
symptoms  are  absent  in  undoubted  cases  of  the  disease.  This  nat- 
urally leads  to  the  malady  itself  not  being  recognized,  though  actually 
present.  Thus,  I  have  several  times  been  called  in  consultation  in 
cases  of  true  tabes,  not  recognized  because  of  the  absence  of  locomotor 
ataxia,  while  the  gastric  crises  accompanied  by  severe  vomiting  were 
present.  But  this  disadvantage  is  especially  characteristic  of  Graves' 
disease  from  the  name  of  exophthalmic  goiter  being  so  commonly 
given  to  it.  In  my  monograph  on  "Graves'  Disease,  With  and 
Without  Exophthalmic  Goiter,"  I  detailed  the  history  of  41  cases  in 
which  there  was  exophthalmos  and  goiter,  and  compared  them  with 
27  cases  of  true  Graves'  disease,  in  which  there  was  neither  goiter  nor 
exophthalmos.  We  should  note  here  that  there  is  no  chronic  affection 
which  has  so  many  characteristic  symptoms  as  Graves'  disease,  at 
least  in  its  grouping.  Hence,  it  presents  us  with  a  clinical  picture 
which  is  more  definite  and  unmistakable  than  any  other  known  serious 
malady. 

To  demonstrate  this  fact,  we  give  the  following  distmctly  charac- 
teristic symptoms  of  Graves'  disease,  excluding  both  goiter  and  exoph- 
thalmos from  the  list.  These  symptoms  are  twenty-seven  in  number 
and  are  as  follows: 

1.  Tachycardia.  6.  Mental  symptoms: 

2.  Palpitation.  (a)  Depression. 

3.  Nervousness.  (b)  Changes  of  disposition. 

4.  Muscular  tremors,  general  and  special,  (c)  Mania. 

with  these  characters:  7.  Special  affections  of  the  ears. 

(a)  General  muscular  weakness.  8.  Special  affections  of  the  eyes. 

(b)  Local  weakness  of  the  kness.  9.  Affefctions  of  smell. 

(c)  Local  weakness  of  the  voice.  10.  Pains: 

(d)  Abasia.  (a)  General. 

(e)  Aphasia.  (b)  Localized   in  neck,  finger-tips, 

5.  Local  paralyses.  nose,  heels,  and  in  external  ears. 

(c)   Muscular  pains. 


474  CLINICAL   MEDICINE 

11.  Headaches.  20.  Pigmentation  of  the  skin. 

12.  Vertigo.  21.  Itching. 

13.  Paresthesias.  22.  Sweating. 

14.  Characteristic  disorders  of  the  stom-        23.  Irritability  of  the  bladder  or  vesical 

ach.  irritability. 

15.  Characteristic  disorders  of  the  intes-        24.  All  symptoms  worse  in  the  morning 

tines.  and  better  in  the  evening. 

16.  Bulimia.  25.  Disease  chronic. 

17.  Emaciation.  26.  Family  complaint. 

18.  Insomnia.  27.  Death  sudden  from  syncope. 

19.  Loss  of  hair. 

Now,  the  theory  of  the  thyroid  origin  of  Graves'  disease  affords  no 
explanation  to  the  greater  Hability  of  women  to  the  complaint.  In 
my  list  of  the  patients  with  goiter  there  are  36  women  to  6  men,  and 
of  those  without  goiter  24  women  to  4  men,  a  ratio  in  keeping  with 
other  statistics  of  this  disease.  It  is  difficult  to  imagine  why  the 
thyroid  itself  should  so  differ  betwen  the  sexes  as  to  account  for  the 
,  preponderance  of  women,  but  it  is  quite  otherwise  when  we  take  into 
account  the  proneness  of  women  to  gastro-intestinal  derangements  in 
connection  with  menstruation,  pregnancy,  and  the  menopause. 
Lastly,  I  hold  that  the  results  of  treatment,  based  upon  the  gastro- 
intestinal origin  of  the  toxemia  of  Graves'  disease,  are  unmistakably 
superior  to  any  measures,  whether  medical  or  surgical,  devised  on  the 
thyroid  theory,  and  which  all  go  to  confirm  the  inference  that  diet 
and  digestion  and  disorders  connected  therewith  are  the  chief  factors 
in  the  etiology  of  Graves'  disease. 

The  mechanism  of  the  exophthalmos  is  as  yet  wholly  unexplained. 
Like  the  other  symptoms  of  the  complaint  it  is  variable  in  its  incidence. 
In  my  42  cases  who  had  goiter  it  was  present  in  19,  among  whom  it 
was  but  slight  in  5,  present  in  one  eye  only  in  i,  and  in  both  eyes  in  i 
woman  who  had  no  goiter  at  all.  It  was  absent  in  the  remaining  22. 
This  variability  in  the  occurrence  of  exophthalmos  in  my  list  is  in 
keeping  with  the  records  of  others.  Glycosuria  is  an  occasional  epi- 
phenomenon  in  Graves'  disease,  but,  though  some  writers  make  a  great 
deal  of  it,  I  would  not  assign  to  it  any  more  important  relationship 
than  I  would  to  albuminuria. 

A  further  clinical  fact  should  be  emphasized,  namely,  that  the 
majority  of  these  symptoms,  whether  motor,  sensory,  or  nutritive,  are 
pecuHar  in  the  forms  which  they  assume  in  Graves'  disease,  and  unlike 
similar  symptoms  in  other  affections,  as  we  shall  now  see;  which  proves 
that  none  other  than  Graves'  disease  is  present,  though  both  thyroid 
enlargement  and  eye  protrusion  are  equally  wanting.  Not  till  this  is 
done  can  one  recognize  the  singular  definiteness  of  this  disease.     In 


GRAVES     DISEASE  475 

each  of  my  fatal  cases  without  goiter  scarcely  one  of  the  above  outlined 
characteristics  failed  to  occur,  while  with  the  remainder  the  average 
frequency  of  their  incidence  is  the  same  between  those  with  and  those 
without  goiter. 

Tachycardia. — The  first  of  these  specific  symptoms  of  Graves'  dis- 
ease is  a  long-continued  rapid  action  of  the  heart.  To  be  characteris- 
tic, the  pulse  should  range  from  go  to  120  or  more,  and  such  frequency 
should  be  chronic  and  persistent,  always  present  at  every  examination 
through  months  and  it  may  be  years,  and  be  entirely  independent  of 
any  other  cause  of  tachycardia.  It  is  this  pronounced  tachycardia  of 
Graves'  disease  which  will  then  be  recognized  as  pecuHar  and  specific, 
and,  therefore,  dependent  on  its  own  particular  cause  without  the  par- 
ticipation of  any  different  element  or  condition. 

These  postulates  would  exclude,  to  begin  with,  all  cases  of  rapid 
action  of  the  heart  from  nervous  excitement.  Patients  with  Graves' 
disease  very  generally  appear  to  be  under  the  same  undue  agitation 
which  makes  the  hand  shake  and  the  voice  tremble.  It  is  easy,  there- 
fore, to  mistake  their  tachycardia  for  the  rapid  pulse  of  merely  excited 
patients,  particularly  as  they  themselves  often  complain  that  they  are 
nervous,  and  this  mistake  is  all  the  more  Hkely  if  the  existence  of 
Graves'  disease  does  not  occur  to  the  physician  because  of  the  absence 
of  goiter  and  exophthalmos,  but  time  and  repeated  examinations  will 
show  the  difference  from  the  merely  excited  pulse  to  be  great  and  unmis- 
takable. Those  who  are  only  nervous  will  ere  long  calm  down,  and 
the  pulse-rate  will  fall  accordingly.  The  Graves'  pulse  never  cahns 
down,  however  quiet  the  patient  may  become.  It  nms  as  fast  or 
faster  than  in  any  fever  or  inflammation,  by  day  and  by  night,  and  also 
in  sleep,  with  less  change  at  each  coimting  over  long  periods  than  in 
any  other  affection.  Equally  easy  is  it  to  exclude  the  quick  pulse 
in  anemic  or  debiUtated  patients  after  physical  exertion,  because  then 
it  soon  falls  with  rest,  particularly  after  lying  down,  but  the  tachycardia 
of  Graves'  disease  may  continue  with  Uttle  or  no  change,  though  the 
patient  be  kept  recumbent  for  months  at  a  time. 

The  tachycardia  of  all  fevers  can  be  at  once  excluded  by  the  ther- 
mometer, which  in  Graves'  disease  rarely  varies  from  normal. 

Graves'  disease  cannot  be  termed  a  febrile  complaint;  and  hence 
its  pulse-rate  has  no  connection  with  such  a  condition. 

Inflammatory  or  organic  changes  in  the  heart  itself  can  equally  be 
excluded  as  causes  of  this  tachycardia.  Instead  it  is  remarkable  how 
long  this  overaction  of  the  heart  may  continue  in  Graves'  disease  with- 
out showing  postmortem  either  hypertrophy  or  inflammatory  lesions 


476  CLINICAL  MEDICINE 

of  any  kind.  In  some  the  heart  walls  are  found  postmortem  more  or 
less  degenerated,  but  not  more  so  than  the  texture  of  other  organs, 
which  suffer  alike  from  the  widespread  derangement  of  nutrition  which 
precedes  death  in  this  complaint. 

Tachycardia  is  an  occasional  accompaniment  of  certain  cerebro- 
spinal affections,  particularly  tabes,  but  these  in  turn  can  be  excluded 
by  the  entire  absence  of  their  characteristic  symptoms  in  Graves' 
disease. 

After  all  such  causes  of  rapid  heart  action  are  excluded  the  pro- 
nounced and  strikingly  persistent  tachycardia  of  Graves'  disease  then 
appears  as  a  singular,  pathognomonic  symptom.  No  other  form  of 
tachycardia  compares  with  it  for  long  continuance.  I  have  known  it 
to  remain  imchanged  for  nine  years,  and  in  more  than  half  of  the  cases 
it  lasts  over  two  years.  It  must  also  hold  some  important  relation  to 
the  disease  itself,  which  is  far  more  constant  than  either  the  goiter  or 
the  exophthalmos,  for  I  found  it  absent  in  only  2  of  my  70  cases.  These 
considerations  definitely  indicate  that  this  peculiar  state  of  the  heart 
constitutes  one  of  the  essential  symptoms  of  Graves'  disease,  but  this 
tachycardia  is  found  fully  as  often,  and  quite  as  marked,  in  those 
patients  who  show  no  evidence  of  thyroid  enlargement  as  in  those 
who  do. 

Palpitation  as  a  symptom  is  quite  distinct  from  tachycardia-,  for 
the  latter  may  exist  in  high  degree,  as  in  fever,  and  yet  the  patient  be 
wholly  non-cognizant  of  it.  On  the  contrary,  the  patient  is  always 
conscious  of  palpitation,  and  frequently  is  much  alarmed  by  it.  He 
feels  the  heart  stop,  then  bound  violently,  then  beat  irregularly,  then 
rapidly,  all  in  turns,  and  if  it  occurs  at  night  i't  banishes  sleep  by  the 
nervousness  which  it  occasions. 

We  may  say  here  that  in  all  which  follows  we  propose  to  demon- 
strate that  the  origin  of  Graves'  disease  is  not  due  primarily  to  any 
affection  of  the  thyroid  gland.  Instead,  where  the  thyroid  gland  is 
hypertrophied  in  this  complaint,  the  goiter  is  secondary,  and  not  the 
original  cause  of  Graves'  disease,  just  as  enlargement  of  the  spleen 
may  occur  in  malarial  fever,  but  may  also  occur  in  other  affections 
which  have  no  connection  with  malaria. 

Among  the  prominent  symptoms  of  Graves'  disease  are  pains,  of 
great  variety  as  to  their  seat  and  nature,  for  they  are  both  general  and 
local  in  their  distribution,  but  nevertheless  they  usually  present  some 
features  in  common  which  render  them  characteristic  of  this  malady. 
Some  of  these  pains  are  characteristic  on  account  of  the  parts  impli- 
cated, like  the  palms  of  the  hands,  the  tips  of  the  fingers,  and  ends  of 


graves'  disease  47y 

toes  and  heels.  In  one  case  without  goiter  the  pakns  of  the  hands  were 
extremely  painful.  Pains  in  the  tips  of  the  fingers  were  noted  in  6 
cases  with  goiter  and  in  5  cases  without  goiter;  in  the  toes  in  2  cases  of 
goiter  and  in  3  cases  without  goiter.  Pains  in  the  heels  were  noted  m  i 
case  with  goiter  and  in  5  cases  without  goiter.  They  were  all  char- 
acterized by  sensitiveness  to  pressure,  Hke  the  tenderness  of  the  exter- 
nal ears,  and  in  those  in  whom  the  heels  were  involved  walking  was 
rendered  difficult.  The  tenderness,  however,  in  all  cases  seemed  to 
be  very  superficial,  and  not  even  when  in  the  heels  could  it  be  termed 
articular,  for  the  ankle-joint  could  be  freely  moved  without  pain. 

True  muscular  pains,  on  the  other  hand,  are  very  frequent,  and  in 
patients  without  goiter  are  often  mistaken  for  rheumatism,  as  the 
affected  muscles  become  stiff  and  painful  upon  movement.  They 
differ  from  rheumatism  in  that  the  muscles  implicated  are  not  pain- 
ful on  firm  palpation,  show  no  heat  or  swelling,  are  not  affected  by 
changes  in  the  weather,  and,  moreover,  the  pains  are  very  shooting, 
appearing  and  disappearing  much  more  rapidly  than  do  rheumatic 
pains,  and  very  commonly  are  better  in  the  evening  than  in  the  morn- 
ing. Unlike  muscular  rheumatism,  they  rarely  are  referred  to  the 
back.  One  of  the  commonest  sites  is  in  the  muscles  of  the  neck,  par- 
ticularly in  the  sternomastoid  and  the  upper  division  of  the  trapezius. 
The  left  side  of  the  neck  is  affected  about  twice  as  often  as  the  right, 
having  been  noted  in  7  cases  with  goiter  on  the  left,  in  5  cases  with 
goiter  on  the  right,  and  in  3  cases  with  goiter  on  both  sides,  while  in 
the  cases  without  goiter  they  occurred  in  5  patients  on  the  left,  in  2 
on  the  right,  and  in  i  on  both  sides. 

These  pains,  moreover,  may  affect  the  muscles  of  both  the  upper  and 
lower  extremities  quite  extensively.  One  case,  a  lady,  for  two  years 
before  goiter  developed  was  greatly  annoyed  with  nocturnal  pains 
in  the  anterior  aspect  of  both  thighs;  and  the  same  kind  of  pains 
occurred  in  i  case  without  goiter.  These  pains  should  all  be  distin- 
guished from  peripheral  neuritis  by  their  transient  character,  and  from 
true  neuralgic  pains  by  their  tenderness  to  pressure  and  by  their  caus- 
ing muscular  stiffness.  In  a  few  instances  the  joints — especially  the 
wrist,  knees,  and  ankles — became  painful,  when  the  differentiation 
from  rheumatism  became  more  difficult,  and  it  was  only  the  presence  of 
other  symptoms  of  Graves'  disease  which  served  to  distinguish  them. 
From  gouty  arthritis  they  can  be  distinguished  by  the  absence  of  the 
painful  points  on  the  condyles. 

Headache. — Among  the  commonest  sensory  disturbances  of  Graves' 
disease  are  headaches.     With  many  patients  they  are  almost  of  daily 


478  CLINICAL   MEDICINE 

occurrence,  particularly  in  the  morning.  I  was  early  struck  with 
their  migrainous  character,  especially  when  accompanied  with  nausea 
or  other  gastric  disturbance.  This  was  further  borne  out  by  the  func- 
tional derangements  of  the  eyes,  which,  though  not  assuming  the 
definite  teichopsia  of  migraine,  yet  flashes  of  light,  dark  and  bright- 
colored  spectra,  and  pain  in  the  eyes  are  frequently  mentioned.  They 
differ  from  tj^ical  attacks  of  migraine  in  not  coming  on  in  severe  parox- 
ysms, followed  by  complete  cessation  for  more  or  less  prolonged  periods, 
and  they  rarely  lead  to  vomiting.  In  other  respects  they  so  resemble 
migraine  that  finally  I  was  led  to  ask  if  the  patients  themselves  had 
suffered  from  migraine  previously  to  the  development  of  Graves'  dis- 
ease, and  whether  they  had  migrainous  relatives.  The  results  of  these 
inquiries  were  interesting.  Out  of  the  list  of  36  with  goiter  who  were 
questioned,  19  had  suffered  from  migraine  in  previous  years,  11  of 
them  severely.  Particulars  as  to  relatives  were  noted  in  14 — -i  (a 
man)  had  suffered  greatly  from  migraine  from  boyhood  and  so  did  his 
father.  The  rest  were  women.  One  had  a  mother  and  sister  who  had 
goiter,  and  they,  with  three  other  sisters  and  a  brother,  were  martyrs 
to  sick  headaches.  Another  had  an  aunt  and  a  cousin  on  the  mother's 
side  who  had  goiter,  and  they,  with  her  mother's  whole  family,  were 
migrainous,  but  not  her  father's.  Another,  her  mother  and  brother 
suffered  with  migraine.  Two  had  each  a  migrainous  sister,  one  a 
father  very  severely  affected;  one  a  father  and  a  sister-  one  a  mother 
and  a  sister.  Of  the  remaining  12 — 3  men  and  9  women — none  were 
troubled  much  with  headaches.  One,  however,  had  a  mother  who  also 
had  goiter  and  who  had  migraine  badly.  Another  also  had  a.  mother 
with  goiter,  but  in  her  case,  and  in  3  other  patients,  no  family  history 
of  migraine  could  be  eUcited.  Among  the  28  cases  without  goiter,  18 
cases  are  noted  with  headaches,  7  had  suffered  from  migraine,  and  3  had 
no  headaches  at  all.  Flashes  of  Hght  and  scotoma  were  mentioned  in 
4  cases  with  goiter;  and  mentioned  in  8  cases  of  the  patients  without 
goiter.  One  woman,  without  goiter  after  the  disease  developed,  when 
she  was  forty-two  years  of  age  had  headaches  for  the  first  time  and 
often  attacks  of  blindness  in  the  right  eye.  She  had  a  sister  who  had 
goiter  and  who  was  very  migrainous.  Her  mother,  who  suffered 
greatly  from  migraine,  and  finally  died  of  a  disease  whose  nature  neither 
of  her  physicians  (who  were  eminent  New  York  practitioners)  could 
diagnose,  but  which  both  this  patient  and  her  goitrous  sister  were  now 
sure  resembled  their  own  malady.  As  to  relatives,  particulars  were 
obtained  in  8  of  the  cases  without  goiter.  Four  (i  man  and  3  women) 
had  each  a  sister  with  goiter,  who  also  suffered  from  migraine.     One 


graves'  disease  479 

had  two  brothers  who  suffered  from  migraine,  but  her  two  sisters  did 
not.  One  had  a  migrainous  mother,  but  her  three  sisters  were  free. 
One  (a  man)  had  a  mother,  sister,  and  two  brothers  who  had  migraine. 
Two  had  migraine,  but  there  was  none  in  their  famihes.  This  fre- 
quent association  cannot  be  merely  a  coincidence,  and,  as  we  shall  see, 
is  not  without  its  bearing  upon  the  pathology  of  Graves'  disease. 

Vertigo  is  an  occasional  symptom,  and  was  pronounced  in  5  patients 
with  goiter  and  in  5  cases  without  goiter.  Though  it  might  be  expected 
to  be  connected  with  gastric  derangement,  yet  I  found  it  almost  uni- 
formly present  in  the  characters  of  aural  vertigo  instead,  being  most 
pronounced  in  patients  who  suffered  from  tinnitus  or  loss  of  hearing. 
When  severe,  it  had  the  character  of  aural  vertigo,  in  causing  a  great 
sense  of  fright.  The  worst  example  of  the  kind  occurred  in  a  patient 
without  goiter,  who  entirely  lost  her  hearing  in  the  left  ear  until  she 
recovered  from  her  disease,  when  the  hearing  returned  and  the  vertigo 
ceased.  In  no  one  of  the  cases  in  whom  abasia  occurred  was  vertigo 
complained  of. 

Paresthesia. — As  might  be  expected  in  a  disease  with  so  many 
nervous  symptoms,  various  forms  of  paresthesia  are  common.  Of 
these,  tingling  and  numbness  are  the  most  frequent,  and  usually  more 
pronounced  in  the  lower  than  in  the  upper  extremities.  Of  42  patients 
with  goiter,  10  complained  of  paresthesia.  It  is  noticeable  that  numb- 
ness and  tingling  were  frequently  associated  in  time  with  headaches, 
thus  bearing  out  the  resemblance  with  severe  migraine,  in  which  these 
symptoms  are  likewise  common. 

Digestive  Disturbances. — Much  the  most  serious  derangements  in 
Graves'  disease,  for  their  effect  upon  the  nutrition  of  the  body,  are 
those  connected  with  the  functions  of  the  ahmentary  canal.  It  may  be 
said  that  Graves'  disease  increases  in  severity,  and  becomes  dangerous 
to  life,  in  direct  proportion  to  the  degree  in  which  the  gastro-intestinal 
tract  is  involved.  None  of  the  other  derangements,  not  even  the 
tachycardia,  and,  least  of  all,  the  size  of  the  goiter,  seem  so  to  tell  upon 
the  general  health  of  the  patient  as  the  disordered  condition  of  the 
stomach  and  intestines.  The  bearing  of  this  important  element  upon 
the  pathology  itself  of  Graves'  disease,  as  well  as  upon  its  successful 
treatment,  will  be  discussed  later. 

The  first  fact  to  note  about  the  digestive  disorders  of  Graves' 
disease  is  that  they  are  specific  in  their  characters,  and  distinctively 
unhke  other  affections  of  the  gastro-intestinal  tract.  In  contrast  to 
the  variety  in  the  symptoms  of  ordinary  digestive  derangements  in 
different  persons,  the  gastro-intestinal  disorders  of  Graves'  disease  are 


480  CLINICAL  MEDICINE 

almost  uniformly  similar  in  their  chief  features,  however  the  other 
symptoms  of  the  complaint  may  vary  between  different  individuals. 
Thus,  from  their  earliest  developments  to  their  end,  in  fatal  cases  with 
uncontrollable  vomiting  and  diarrhea,  they  never  present  the  charac- 
ter of  inflammatory,  ulcerative,  or  of  exudative  processes.  More- 
over, whether  in  their  sHghter  or  in  their  severer  forms,  they  are  not 
amenable  to  the  ordinary  remedies  prescribed  for  digestive  disorders, 
thus  confirming  the  inference  that  they  are  pecuHar  in  their  dependence 
upon  this  specific  malady.  The  most  significant  fact,  however,  about 
them  is  that,  with  rare  exceptions,  they  develop  not  during  the  course 
of  the  other  derangements,  but  much  before  them.  If  careful  inquiry 
on  this  subject  be  made,  it  is  striking  to  find  how  generally  the  patients 
admit  the  presence  of  digestive  symptoms,  often  for  long  periods  be- 
fore any  of  their  other  derangements. 

Out  of  the  entire  Hst  of  my  cases  of  both  forms  only  4  patients  (2 
with  goiter  and  2  without)  stated  that  they  previously  had  suffered 
from  no  trouble  of  either  stomach  or  bowels.  Two  of  these  patients 
(i  with  goiter  and  i  without)  subsequently  had  attacks  of  apparently 
causeless  diarrhea.  With  2  of  my  cases,  both  without  goiter,  their 
digestive  troubles  began  so  suddenly  that  they  could  give  the  exact 
date  of  their  occurrence.  In  the  majority,  however,  of  both  classes 
the  story  of  their  derangements  was  much  the  same  throughout,  as  if 
the  sjmiptoms  always  remained  the  same  in  kind  from  the  first,  and 
not  like  the  relapsing  or  changing  forms  of  ordinary  gastro-intestinal 
affections. 

Characteristic  Disorders  of  the  Stomach. — Thus,  as  to  the  stomach, 
at  no  time  is  there  any  tenderness  on  palpation  or  any  epigastric 
rigidity,  as  in  gastritis,  ulcerative  or  otherwise.  With  a  number 
of  my  patients  gastric  lavage  had  been  employed  for  relief  of  the 
symptoms,  but  the  uniform  report  was  that  no  mucus  was  found 
in  any  amount  in  the  outflow,  nor  did  the  lavage  afford  relief.  A  com- 
mon symptom  was  nausea,  which,  however,  rarely  led  to  vomiting, 
except  in  advanced  cases.  This  nausea  was  sometimes  extremely  per- 
sistent, in  I  case  without  goiter  continuing  for  fully  two  years  before 
the  tachycardia  and  the  other  derangements  of  the  disease  developed, 
as  they  did  afterward  to  an  alarming  extent.  This  nausea  usually  has 
no  relation  to  the  time  of  eating,  occurring  as  often  with  an  empty 
stomach  as  after  meals.  A  much  more  common  symptom  is  gastric 
flatulence,  which  may  persist  even  after  gastric  discomfort  has  sub- 
sided, but  ordinarily  it  constitutes  one  of  the  most  anno5dng  accompani- 
ments of  the  complaint.     The  patients  may  attempt  to  relieve  it  by 


graves'  disease  481 

eructations,  but  uniformly  deny  that  any  acid  or  acrid  sensation  is 
produced  in  the  throat  or  mouth  if  they  succeed  in  the  attempt.  In- 
stead of  pain,  or  a  sense  of  weight,  or  of  cramps,  they  ordinarily  de- 
scribe their  sensations  as  consisting  of  an  ill-defined  discomfort,  re- 
ferred to  the  stomach,  which  with  many  is  very  distressing. 

In  my  list  of  42  patients  with  goiter,  7  complained  of  frequent 
nausea,  it  was  absent  in  25,  and  not  noted  in  9.  Among  the  28  cases 
without  goiter,  nausea  was  present  in  14  cases;  absent  or  not  noted  in 
14.  Flatulence  and  gastric  discomfort  were  present  in  23  cases  with 
goiter,  and  precisely  the  same  symptoms  were  present  in  21  cases 
without. 

Characteristic  Disorders  oj  the  Intestine. — Intestinal  derangements, 
on  the  other  hand,  are  not  only  both  frequent  and  pronounced  in 
Graves'  disease,  but  they  also  seem  to  hold  a  fairly  constant  relation 
to  the  other  characteristic  symptoms.  This  is  particularly  true  of  the 
tachycardia,  the  nervousness,  and  the  tremors,  which  are  often  ag- 
gravated with  each  exacerbation  of  the  bowel  derangement.  Several 
patients  asserted  that  attacks  of  nocturnal  palpitation  occurred  only 
when  the  bowels  became  loose.  The  immediate  reduction  of  the  pulse- 
rate,  as  we  shall  see,  by  certain  forms  of  intestinal  medication  would 
also  appear  to  confirm  this  surmise.  A  sense  of  diffused  distress 
throughout  the  abdomen,  accompanied  with  flatulence,  is  even  more 
common  than  the  like  symptoms  just  described  in  the  stomach. 
With  some  this  sensation  is  aggravated  with  every  movement  of  the 
"bowels,  occasionally  even  when  the  movement  seems  to  be  regular  and 
natural.     The  most  characteristic  symptom,  however,  is  diarrhea. 

It  was  present  in  25  of  the  patients  with  goiter,  and  in  13  of  those 
without.  It  was  present  in  all  4  of  the  fatal  cases,  becoming  uncon- 
trollable in  each  one.  The  diarrhea  of  Graves'  disease  is  as  peculiar 
in  its  way  as  any  other  accompaniments  of  the  affection.  Its  exciting 
causes  are  usually  difficult  to  determine,  for,  though  indiscretions  in 
diet  can  be  occasionally  adduced,  yet  its  onset  seems  often  without 
any  known  reason.  The  only  exception  to  this  statement  in  my 
patients  was  that  the  indulgence  in  red  meats,  especially  beef,  was 
very  commonly  followed  by  return  of  the  diarrhea  in  those  who  had 
been  free  from  it  after  leaving  off  meats.  The  commonest  time  of 
onset  is  the  latter  part  of  the  night  or  early  morning,  occurring  irregu- 
larly afterward  during  the  day,  and  not  particularly  apt  to  follow  di- 
rectly upon  meals.  The  discharges  are  rarely  preceded  or  followed  by 
pain,  are  not  usually  offensive,  but  are  watery  and  devoid  of  either 
blood,  mucus,  or  pus.     According  to  my  experience,  so  long  as  the 

31 


482  CLINICAL   MEDICINE 

diarrhea  persists  no  headway  is  made  in  the  treatment  of  Graves' 
disease. 

On  the  other  hand,  a  certain  percentage  of  patients  with  Graves' 
disease  never  have  diarrhea,  but  constipation  instead.  This  was 
noted  as  habitual  in  6  cases  with  goiter  and  in  10  cases  without  goiter. 
Among  these  patients,  however,  7  with  goiter  and  4  without  goiter  had 
occasional  attacks  of  diarrhea  alternating  with  constipation.  In 
every  instance  their  diarrhea  was  stated  to  have  occurred  without  any 
imaginable  cause,  and  it  was  both  painless  and  watery.  In  the  cases 
with  constipation,  flatulence  and  a  sense  of  discomfort  were  noted  in 
2  cases  with  goiter  and  in  8  out  of  the  10  cases  without  goiter.  In 
II  cases  with  goiter  and  in  6  cases  without  goiter  the  bowels  were 
stated  to  be  regular  and  normal  in  the  movements.  In  all  of  these, 
however,  the  other  symptoms  of  the  complaint  were  moderate  and  the 
disease  was  only  in  a  mild  form  or  incipient  stage. 

Bulimia,  or  a  sense  of  intense  hunger,  is  mentioned  among  the 
symptoms  of  this  complaint.  It  was  very  marked  in  6  of  my  patients 
with  goiter  (2  men  and  4  women) ;  in  i  of  the  latter  preceding  the  goiter 
by  more  than  two  years,  as  did  in  her  case  all  the  other  symptoms — - 
tachycardia,  tremors,  pains,  etc.  The  commonest  time  for  its  onset 
was  in  the  night.  The  same  symptom  was  present  in  5  cases  without 
goiter. 

Emaciation  is  a  very  notable  symptom  in  the  severe  cases  of  this 
disease.  As  a  rule,  it  is  most  pronounced  in  the  patients  who  have 
suffered  most  from  diarrhea.  One  of  the  worst  cases  among  my 
patients,  however,  was  a  woman  who  had  neither  goiter  nor  diarrhea. ' 
She  had  to  be  padded  to  prevent  the  bones  from  cutting  through  the 
skin.  She  recovered  wholly  in  time,  and  regained  not  only  her  full 
weight,  but  her  physical  strength,  and  lived  an  active  life  for  over  four 
years,  when  she  had  an  acute  relapse,  and  died  suddenly  from  syncope. 
Emaciation  was  very  pronounced  in  17  with  goiter  and  in  6  of  the 
cases  without  goiter. 

Insomnia. — Among  the  frequent  complaints  of  Graves'  disease  is 
insomnia.  We  might  naturally  expect  it  to  be  from  the  extreme  ner- 
vousness to  which  many  of  these  patients  are  subject,  but  I  am  in- 
cUned  to  ascribe  it  more  to  their  digestive  derangements,  as  it  has  all 
the  characteristics  of  the  sleeplessness  of  chronic  dyspeptics.  Thus, 
the  majority  are  more  troubled  with  wakefulness  after  midnight  than 
before,  and  often  in  proportion  to  the  disturbance  of  the  stomach  and 
bowels.  This  insomnia  is  also  but  Httle  relieved  by  soporific  drugs, 
and  improves  only  as  the  digestive  disorders  improve.     Insomnia  was 


graves'  disease  483 

especially  complained  of  by  21  patients  with  goiter  and  by  18  patients 
without  goiter.  In  all  cases  in  which  the  insomnia  was  pronounced  the 
morning  mental  depression  was  naturally  aggravated. 

Loss  of  Hair. — F'alling  out  of  the  hair  is  often  an  early  symptom, 
and  naturally  more  noticeable  among  women.  They  are,  therefore, 
very  certain  of  its  occurrence  and  of  its  state,  compared  with  that  of 
other  symptoms.  It  was  noted  in  21  cases  of  goiter  and  in  6  cases 
without  goiter.  In  i  case  it  included  the  eyebrows.  The  loss  of  hair 
is  not  permanent,  for  it  soon  grows  again  with  the  first  signs  of  general 
improvement.  In  all  respects  it  resembles  the  loss  of  hair  after  pro- 
longed fevers,  like  typhoid,  and  indicates,  therefore,  a  profound  and 
general  toxemia  which  involves  every  process  of  nutrition.  One 
patient  with  goiter  stated,  that  when  the  symptoms  of  acute  Graves' 
disease  developed  upon  a  chronic  goiter  of  thirty-five  years'  standing, 
her  hair,  instead  of  falling  out,  turned  gray,  and  then  returned  again 
to  its  normal  color  when  the  acute  symptoms  had  subsided. 

Pigmentation  of  the  Skin. — This  frequently  occurs  in  brownish- 
colored  and  discrete  patches,  but,  though  classed  by  a  number  of 
writers  as  a  distinctive  S3rmptom  of  Graves'  disease,  I  regard  it  as 
merely  a  sign  of  impaired  nutrition,  for  it  is  quite  similar  to  the  dis- 
colorations  met  with  in  many  wasting  diseases  and  in  chronic  anemics. 
Its  hue  also  varies,  in  some  resembling  the  bronzing  of  Addison's 
disease.     Its  duration  also  is  very  variable. 

Itching  of  the  skin  is  quite  characteristic  of  this  complaint,  more 
especially  in  severe  cases.  Like  all  other  symptoms  of  Graves'  dis- 
ease, it  has  no  connection  with  inflammation,  being  accompanied  with 
neither  redness  nor  eruption.  It  is  apt  to  be  most  troublesome  at  night, 
increasing  the  insomnia  by  its  shifting  character.  Scratching  neither 
reheves  nor  aggravates  it.  It  was  noted  in  13  cases  with  goiter  and  in 
5  cases  without.  In  no  case  among  the  women  was  it  associated  with 
pruritus  vulvae. 

Sweating  is  a  frequent  symptom,  and  not  always  either  nocturnal  or 
indicative  of  an  advanced  condition  of  debility,  for  in  some  patients 
it  occurred  quite  early  in  the  complaint,  before  they  had  become  much 
reduced;  as  in  other  conditions  of  hidrosis,  it  was  variable,  coming  and 
going  without  any  imaginable  reason,  but  in  no  cases  preceded  by 
fever.  In  my  lists  troublesome  sweating  was  reported  in  7  of  the 
goitrous  cases  and  in  4  of  the  non-goitrous  cases. 

Vesical  Irritability. — IrritabiHty  of  the  urinary  bladder,  causing 
frequent  micturition,  is  a  very  common  and  troublesome  complication, 
especially  as  it  is  more  apt  to  occur  at  night,  and  thus  aggravate  the 


484  CLINICAL   MEDICINE 

insomnia  and  nervousness  of  the  patient.  In  full  keeping  with  the 
other  symptoms  of  Graves'  disease  it  has  no  connection  with  inflam- 
mation, and  hence  never  presents  the  accompaniment  of  cystitis,  the 
urine  being  free  from  mucus  and  pus.  It  was  noted  in  14  of  the  cases 
with  goiter  and  in  10  of  the  cases  without. 

All  Symptoms  Worse  in  the  Morning. — If  it  be  asked  what  are  the 
most  peculiar  or  characteristic  clinical  features  ui  Graves'  disease,  I 
would  answer  that,  next  to  its  specific  tachycardia,  is  the  morning 
exacerbation  of  its  chief  symptoms.  No  careful  observer  can  fail  to 
be  struck  by  this  singular  phenomenon.  In  my  notes,  out  of  the  42 
cases  of  goiter  only  4  denied  that  they  were  worse  in  the  morning,  and 
it  is  doubtful  if  one  of  these  (an  Armenian  woman,  who  could  not  speak 
English)  understood  the  question.  On  the  other  hand,  the  remaining 
patients  had  no  hesitation  in  admitting  that  they  were  always  worse 
in  the  morning  and  better  in  the  evening,  and  this  statement  is  quite 
,  as  distinctly  present  in  the  histories  of  the  patients  who  never  showed 
any  change  in  the  thyroid  gland.  Thus,  of  these  28  cases,  morning 
aggravations  were  well  marked  in  25  and  denied  in  only  3,  and  of  each 
of  these  it  might  be  correctly  stated  that  the  disease  was  still  in  an 
incipient  stage.  This  characteristic  of  the  disease  is  all  the  more  ex- 
emplified when  we  pass  from  general  conditions  to  particular  symptoms. 

Thus,  as  to  the  one  symptom  of  muscular  tremor.  In  no  less  than 
6  patients  with  goiter,  and  3  patients  without,  it  was  recorded  that  the 
shaking  of  the  right  hand  prevented  their  writing  in  the  forenoon,  so 
that  they  had  to  wait  until  evening  before  they  could  hold  a  pen.  One 
patient  without  goiter,  not  being  accustomed  to  write  at  all,  yet  said 
that  she  could  not  sew  in  the  morning,  but  could  do  so  in  the  evening, 
but  all  other  leading  symptoms  share  likewise  in  this  curious  diurnal 
variation.  Thus,  the  tachycardia,  instead  of  being  lessened  by  the 
night's  bodily  rest,  is  almost  always  increased  in  the  early  morning 
compared  with  the  previous  evening.  The  commonest  time  for  pal- 
pitation is  also  toward  morning.  The  headaches,  as  might  be  expected 
from  their  migrainous  affinities,  are  far  more  common  in  the  morning 
and  worse  in  their  onset,  and  in  average  cases  they  subside  toward 
evening.  Perhaps  the  most  marked  in  their  morning  visitations  are 
the  periods  of  mental  depression.  Men,  quite  as  much  as  women,  will 
complain  of  their  waking  with  a  heavy  weight  on  their  spirits  and  a 
beclouding  of  the  mind,  wholly  precluding  any  mental  effort  or  con- 
centration of  thought,  and  then  feel  more  like  themselves  at  night. 
Those  also  who  suffer  from  insomnia  often  find  that  they  can  go  to  sleep 
readily,  but  after  midnight  grow  obstinately  wakeful. 


graves'  disease  485 

It  is,  however,  with  patients  who  have  diarrhea  that  this  compUca- 
tion  is  the  most  uniformly  worse  as  morning  approaches.  The  first 
onset  of  this  symptom  also  in  those  who  before  have  been  free  is 
scarcely  ever  in  the  daytime,  but  in  the  early  morning.  When  diarrhea 
occurs  it  is  noteworthy  how,  along  with  it,  increased  tachycardia,  pal- 
pitation, and  nervous  depression  occur,  and  too  uniformly  to  doubt  that 
at  this  period  there  must  supervene  a  marked  increase  in  the  specific 
toxemia  of  the  disease.  An  analogous  aggravation  of  symptoms  in  the 
early  morning  is  common  in  melancholia,  and  in  those  ill-defined 
nervous  derangements  now  classed  under  the  elastic  term  "neuras- 
thenia." But  in  melanchoHa  this  feature  is  by  no  means  so  uniform 
as  in  Graves'  disease,  while  I  do  not  doubt  that  many  cases  of  so-called 
neurasthenia  are  really  examples  of  unrecognized  Graves'  disease. 
This  morning  element  can  only  be  ascribed  to  derangements  in  vital 
chemistry,  but  whether  that  can  be  explained  by  the  increased  activity 
of  the  thyroid  gland  after  midnight  will  be  discussed  under  the  head 
of  Pathology. 

Chronicity. — There  is  one  element  in  Graves'  disease  which,  when 
duly  considered,  fully  demonstrates  its  distinct  and  specific  nature, 
and  that  is  its  chronicity.  With  all  its  multitudinous  develop- 
ments in  deranged  functions  it  remains  the  same  throughout  a  long 
course  and  never  merges  into  anything  else.  All  its  chief  symptoms 
preserve  the  same  characteristics,  however  long  they  continue.  Thus, 
its  tachycardia  continues  through  months  and  years,  as  no  other  tachy- 
cardia ever  does,  with  meantime  surprisingly  little  change  of  any  other 
kind  in  the  overacting  organ.  But  the  tachycardia  is  not  an  isolated 
phenomenon  in  Graves'  disease,  instead  it  is  uniformly  accompanied 
by  a  characteristic  train  of  other  symptoms,  which  are  as  much  a  part 
of  the  malady  as  it  is,  and  which  also  continue  with  Httle  variation  and 
httle  modification.  The  gastric  derangement  never  becomes  a  gastri- 
tis nor  the  diarrhea  an  enteritis  or  a  colitis. 

My  own  experience  leads  me,  therefore,  to  hesitate  in  pronouncing 
any  patient  cured  who  has  had  Graves'  disease  fully  developed  until 
a  long  time  has  elapsed  after  apparent  recovery.  Instead,  I  always  tell 
patients  that  they  must  expect  to  keep  up  their  treatment  for  at  least 
two  years  before  they  can  be  sure  of  complete  recovery.  On  that 
account  I  am  skeptical  of  some  reported  rapid  cures  after  certain  pro- 
cedures, especially  surgical  ones,  as  I  want  to  know  more  of  the  after- 
history  of  the  patients.  A  certain  proportion  improve,  or  even  recover 
spontaneously,  but  I  have  found  that  relapses  are  common,  sometimes 
after  intervals  of  years.     Most  of  the  observations  which  I  have  read 


486  CLINICAL  MEDICINE 

on  this  disease  are  based  upon  the  dinical  histories  of  hospital  patients, 
not  many  of  them  extending  beyond  a  few  months,  whereas  two  years 
is  not  too  long,  and  one  year  is  not  enough,  for  a  satisfactory 
history. 

One  reason  for  referring  to  the  chronic  course  of  Graves'  disease 
is,  that  this  of  itself  shows  that  it  is  no  passing  ailment  which  might 
give  opportunities  for  mistakes  in  diagnosis.  Whoever  has  a  com- 
plaint, with  always  the  same  symptoms,  for  two  or  three  years  ought 
by  that  time  to  have  his  trouble  recognized  as  the  same,  and  not  as 
something  else,  even  if  we  cannot  give  it  a  name;  and  it  is  just  because 
those  cases  without  exophthalmic  goiter  are  not  a  whit  different  in 
this  feature  of  chronicity  from  those  with  goiter,  that  they  must  be 
classed  as  true  cases  of  Graves'  disease.  It  is  no  more  justifiable  to 
apply  the  terms  "incomplete,"  ''latent,"  or  "abortive"  to  them,  when 
the  patients  suffer  severely  for  months  together  from  the  characteristic 
derangements  of  the  disease,  than  it  would  be  to  designate  a  case  of 
phthisis  as  latent  or  incomplete  because  throughout  the  long  course 
there  was  entire  absence  of  hemoptysis. 

As  with  other  chronic  maladies,  however,  cases  do  occur  of  acute 
Graves'  disease.  Thus,  as  already  mentioned,  2  of  my  patients  with- 
out goiter  could  fix  the  exact  day  on  which  the  trouble  began.  One 
in  my  Hst  of  cases,  with  fully  developed  goiter,  whom  I  saw  in  consul- 
tation, gave  a  history  of  only  five  weeks'  illness;  another,  who  developed 
dangerous  acute  symptoms,  had  been  ill  only  two  months;  and  there 
are  numerous  instances  reported  of  the  sudden  development  of  exoph- 
thalmic goiter;  still,  acute  Graves'  disease  is  a  rarity,  the  rule  being 
that  it  begins  imperceptibly  and  continues  indefinitely  as  to  time,  but 
most  definitely  otherwise  in  the  progressive  development  of  a  long  array 
of  derangements  which  are  peculiarly  its  own. 

Family  Complaint. — One  of  the  most  conclusive  evidences  of  the 
identity  of  the  disease  in  the  non-goitrous  with  the  goitrous  patients 
on  my  list,  is  their  equal  share  in  the  occurrence  of  Graves'  disease 
among  their  relatives.  That  Graves'  disease  is  a  family  complaint 
has  long  been  known.  Thus,  in  my  list  of  42  patients  with  goiter,  6 
had  relatives  who  were  subject  to  this  complaint.  But,  turning  for 
comparison  to  my  patients  without  goiter,  6  had  relatives  who  had 
goiter.  This  percentage  among  them  of  family  liability  to  Graves' 
disease  certainly  cannot  be  ascribed  to  coincidence,  particularly  as 
Graves'  disease  (quite  unlike  phthisis)  is  not  a  common  affection  in  any 
community.  I  may  add  that  I  have  been  particular  to  inquire  whether 
it  was  Graves'  goiter,  and  not  other  forms  of  goiter,  which  the  relatives 


graves'  disease  487 

had.  The  value  of  this  element,  in  proving  that  the  non-goitrous  cases 
had  Graves'  disease,  is  sufficiently  shown  in  the  enumeration  of  the 
instances  noted  in  the  records. 

Death  Sudden. — In  fatal  cases  the  terminal  symptoms  of  Graves' 
disease  are  as  characteristic  as  those  of  the  preceding  stages.  If  a 
patient  be  lying  in  bed,  the  persistent  tachycardia  changes  to  extreme 
irregularity  of  the  pulse  in  frequency  and  in  size,  becoming  often  un- 
countable in  rapidity,  then  thready,  then  intermittent,  and  sometimes 
apparently  slow  from  failure  of  the  cardiac  systole  to  reach  the  radial. 
Then  it  suddenly  stops,  and  all  is  over,  without  a  struggle.  If  the 
patient  be  sitting  up,  as  they  often  do  in  spite  of  remonstrance,  the 
end  comes  in  the  same  sudden  but  quiet  fashion. 

Previously  to  this,  however,  the  story  of  the  antecedent  symptoms 
is  remarkably  uniform.  Their  nervousness  has  increased  to  distress- 
ing restlessness,  deHrium  sometimes  resembling  mania  sets  in,  and  with 
it  an  obstinate  refusal  to  accede  to  the  recommendations  of  their  friends, 
particularly  in  refusing  to  take  remedies.  The  most  common  precursor 
is  the  supervention  of  persistent  vomiting  and  diarrhea.  As  disturb- 
ances of  the  gastro-intestinal  tract  always  hold  the  first  place  in  their 
serious  effects  upon  the  strength  and  nutrition  of  patients  with  Graves' 
disease,  so  it  is  due  directly  to  their  becoming  uncontrollable  that  death 
ends  the  scene.  But,  as  will  be  seen  presently,  this  clinical  picture  is 
substantially  the  same  in  my  2  fatal  cases  with  goiter  and  in  the  2 
without  goiter. 

Pathology. — After  years  of  experiments  on  animals,  of  the  effect  of 
depriving  the  system  of  the  thyroid  secretion  by  excision  of  the  gland, 
it  was  inferred  that  in  carnivora  this  operation  was  rapidly  fatal,  in 
omnivora  and  herbivora  scarcely  at  all.  The  latter  seem  generally  to 
get  along  quite  well  without  the  thyroids,  a  curious  illustration  of  which 
is  shown  by  recent  treatment  of  Graves'  disease,  recommended  by 
Lanz,  Mobius,  and  other  writers,  by  large  quantities  of  milk  of  goats, 
which  has  been  thyroidectomized.  The  effects  of  the  removal  of  the 
thyroids  differed  materially,  according  to  the  normal  diet  of  the  animal 
experimented  upon.  On  the  other  hand,  some  confusion  in  the  inter- 
pretation of  the  symptoms  following  the  thyroidectomy  was,  from  over- 
looking the  presence  of  the  small  bodies,  called  parathyroid.  Usually 
embedded  in  the  thyroid  itself,  but  in  rabbits  the  parathyroids  are  quite 
separate  from  the  thyroid.  Thyroidectomy  causes  httle  effect  in  them, 
while  removal  of  the  parathyroid  in  them,  leaving  the  thyroid  intact, 
shows  a  full  train  of  characteristic  nervous  symptoms,  such  as  tetany 
and  tremors.     Again,  tne  severity  of  the  toxemia  in  Graves'  disease 


488  CLINICAL   MEDICINE 

bears  no  relation  to  the  degree  of  thryoid  hypertrophy,  if  that  be  taken 
as  an  index.  The  thyroid  enlargement,  when  it  occurs,  is  wholly  unlike 
parenchymatous  goiter,  in  being  variable  in  every  respect,  increasing 
or  diminishing,  or  even  disappearing,  with  little  or  no  correspondence 
with  the  general  symptoms.  In  practice  I  pay  no  attention  at  all  to 
the  thyroid,  and  never  prescribe  for  its  enlargement,  and  expect  it  to 
disappear  of  its  own  accord  after  treatment  of  wholly  different  func- 
tions. Moreover,  this  theory  fails  altogether  to  accoimt  for  the  clinical 
fact,  which  I  have  now  sufficiently  demonstrated,  that  Graves'  disease 
may  occur  without  any  sign  of  implication  of  the  thyroid  gland,  while 
the  general  toxemia  is  as  great,  and  may  be  as  fatal,  as  in  many  patients 
who  have  goiter.  These  cases,  therefore,  cannot  be  regarded  as  in  any 
sense  incomplete  or  abortive  forms  of  this  very  specific  malady,  and 
imply,  instead,  that  implication  of  the  thyroid  is  a  secondary  and  not  a 
primary  element  in  the  etiology  of  the  affection. 

Treatment. — There  is  scarcely  any  specific  malady  whose  symptom- 
atic treatment  is  so  unsatisfactory  as  that  of  Graves'  disease.  If  the 
case  be  really  severe,  it  will  be  found  that  the  tachycardia  is  wholly 
uncontrollable  by  the  usually  prescribed  remedies  for  cardiac  dis- 
orders, whether  of  a  strengthening  or  of  a  sedative  kind.  The  nervous- 
ness is  not  allayed  by  bromids.  No  ordinary  prescriptions  for  dyspep- 
sia relieve  the  gastric  distress  of  flatulence.  The  diarrhea  is  not  checked 
by  astringents  nor  the  insomnia  helped  by  soporifics,  while  the  emacia- 
tion continues  progressive  and  the  weakness  grows  apace  despite  all 
restoratives. 

Such  conditions  prove  that  one  specific,  underlying  cause  is  the 
common  origin  of  the  whole  array  of  symptoms,  and  so  long  as  that 
specific  cause  is  not  dealt  with  the  separate  treatment  of  resulting 
symptoms  necessarily  can  be  of  no  avail. 

It  was  an  unmistakable  demonstration  of  the  effect  of  diet  in  a 
serious  and  ultimately  fatal  case  of  Graves'  disease  which  first  led  me  to , 
suspect  that  the  toxemia  had  its  origin  in  the  gastro-intestinal  tract. 
This  patient,  after  every  remedy — medicinal  or  otherwise — ordinarily 
prescribed  for  Graves'  disease  had  been  tried  without  success,  began  to 
improve  at  once,  until  she  apparently  recovered  on  being  restricted  to 
the  use  of  fermented  milk  instead  of  meat.  She  then  resumed  the  meat 
diet  and  forthwith  relapsed.  Discontinuing'the  meat,  and  resuming  the 
milk,  she  rapidly  improved  again.  She  then  refused  to  continue  the 
use  of  milk  and  returned  to  meat,  with  the  result  that  her  malady 
became  uncontrollable,  and  soon  ended  in  death.  The  relation  of 
cause  and  effect  in  the  quality  of  her  food,  as  regards  both  improvement 


graves'  disease  489 

and  relapse,  was  as  clearly  shown  as  could  be  desired  in  any  instance 
of  the  disease. 

The  dependence  of  the  entire  train  of  symptoms  of  Graves'  disease, 
not  upon  any  state  of  the  thyroid,  but  on  what  is  ingested  in  the  ali- 
mentary canal,  may  be  experimentally  tested  any  time.  Let  a  patient 
with  a  temporary  improvement  in  the  symptoms  partake  heartily  of 
beef  three  times  a  day,  particularly  at  night,  and  immediate  relapse 
will  occur.  Every  one  of  the  characteristic  disorders  will  be  as  surely 
aggravated  as  those  of  a  diabetic  upon  a  free  indulgence  in  starches. 
Taken  as  a  whole,  my  experience  is  that  really  developed  cases  of 
Graves'  disease  without  exophthalmic  goiter  are  more  difficult  to  treat 
than  those  with  goiter. 

It  is  always  advisable  to  impress  upon  the  patients  in  the  beginning 
that  their  malady,  when  fully  estabUshed,  is  not  easy  to  cure,  and 
that  they  will  have  to  continue  in  the  course  recommended  for  at  least 
two  years,  whatever  improvement  has  been  secured.  Most  patients 
of  ordinary  intelligence  can  be  made  to  see  that  all  derangements  of 
digestion,  if  they  have  continued  for  any  length  of  time,  will  then  re- 
quire time  to  correct.  Any  diarrhea,  for  example,  whatever  its  orig- 
inal cause,  which  has  lasted  two  years  cannot  be  expected  to  cease 
without  prolonged  attention  to  dietetic  rules,  as  well  as  to  remedies 
to  prevent  relapses.  Hence,  in  any  disease  characterized  by  so 
many  different  disorders  as  Graves'  disease,  nothing  short  of  the 
utmost  perseverance  in  a  systematic  course  of  treatment  will  insure 
ultimate  recovery.  I  have  always  found  that  relapses  recur  only  after 
the  patients  have  violated  instructions  about  diet.  Diet,  therefore, 
ranks  first  in  importance  in  the  treatment  of  Graves'  disease.  Every- 
thing else  should  be  regarded  as  subordinate  to  that  of  diet.  When  the 
disease  has  got  a  firm  hold  on  the  patient,  if  he  continues  to  eat  freely 
of  red  meats,  such  as  beef,  veal,  mutton  or  pork,  nothing  becomes 
plainer  than  the  futility  of  drugs.  For,  so  long  as  the  poison  is  formed 
in  the  digestive  tract,  and  then  absorbed  into  the  blood,  what  follows 
is  a  paralysis  of  all  vasoconstrictors  throughout  the  body,  the  arterial 
system  everywhere  relaxing,  and  the  whole  train  of  vascular  nervous 
and  secretory  symptoms  characteristic  of  Graves'  disease  developing 
as  a  consequence. 

As  milk  constitutes  much  the  safest  food  for  this  disease,  enough 
to  be  by  itself  sufficient  to  cure  many  cases  without  any  other  treatment, 
its  administration  as  a  remedy  merits  more  than  a  passing  considera- 
tion. This  fact  is  well  known  and  acted  upon  by  all  races  of  men  who 
have  to  Hve  on  milk  as  their  chief  article  of  food,  such  as  the  Bedouins, 


490  CLINICAL  MEDICINE 

the  Tartars,  the  Guacos  of  South  America,  etc.,  who  subsist  on  the 
milk  of  cows,  goats,  sheep,  and  asses.  A  Bedouin  cannot  be  persuaded 
to  drink  fresh  milk  any  more  than  we  would  eat  raw  potatoes.  They 
always  ferment  milk  first,  for  a  very  physiologic  reason,  as  fresh  milk 
has  first  to  be  curdled  in  the  stomach  before  it  can  be  digested.  Any 
quantity  of  it  uses  up  so  much  of  the  pepsin  of  the  stomach  that  not 
enough  then  remains  to  dissolve  the  precipitated  casein,  and  large 
masses  of  hard  curds  remain  to  disturb  digestion,  or,  as  many  express 
it,  they  are  made  bilious  by  it.  By  artificially  curdling  it  first  the 
stomach  is  spared  this  proeess  of  digestion,  and  the  ferment  usually 
employed  is  the  yeast  plant.  By  some  Tartar  tribes  the  lichen 
called  Kefir  is  used  instead,  and  an  excellent  article  is  made  by  it. 

Throughout  western  Asia  and  Egypt  a  piece  of  dough  is  put  into 
the  milk  to  make  the  first  specimen,  but  after  that  enough  of  the 
fermented  milk  is  preserved  each  day  to  add  to  the  fresh  milk.  When 
so  prepared  it  is  doubtful  if  there  be  any  more  digestible  or  complete 
food,  for  milk  contains  every  ingredient  in  its  due  proportion  out  of 
which  the  body  may  be  built  up,  as  the  growth  of  all  young  mammalia 
proves.  With  this  fermented  milk  I  have  been  able  to  cure  the  most 
difficult  of  gastric  disorders,  particularly  those  characterized  by  vomit- 
ing. Even  in  cancer  of  the  stomach  I  have  known  it  to  be  borne  when 
every  other  article  of  diet  was  rejected. 

Anyone  can  learn  to  live  largely  on  fermented  milk,  as  is  demon- 
strated on  an  extensive  scale  by  its  universal  use  in  western  Asia, 
Egypt,  etc.,  and  I  have  found  most  of  my  patients  have  become  fond 
of  it.  Others,  however,  assert  that  they  cannot  bring  themselves  to 
continue  its  use,  and  many  have  used  instead  milk  peptonized  by 
Fairchild's  peptonic  powders.  Others  get  along  with  milk  diluted 
with  an  equal  part  of  Vichy  or  lime-water.  Milk  and  cream  can  also 
be  used  freely  with  cereals,  and  is  all  the  better  digested  if  sweetened 
with  sugar  in  moderate  quantities. 

Poultry  is  usually  well  borne,  provided  it  be  not  kept  too  long. 
Fish  is  allowable,  excluding,  however,  the  more  oily  kinds.  Boiled 
fish  is  usually  more  difficult  of  digestion.  Oysters,  as  a  rule,  agree  well. 
No  more  than  two  eggs  should  be  taken  in  a  day.  Bread  is  an  excellent 
article,  and  may  be  taken  freely  with  butter,  but  in  all  cases  should  be 
as  crusty  as  possible.  Of  the  cereals,  oatmeal  in  any  form  should  be 
avoided,  but  hominy,  well  boiled,  and  rice  are  good.  Of  the  vegetables, 
beans  and  peas  are  injurious,  but  string  beans  may  be  taken  freely. 
Asparagus,  tomatoes,  beets,  carrots,  and  spinach  are  to  be  avoided. 
I  have  found  potatoes  generally  well  borne.     When  diarrhea  is  per- 


graves'  disease  491 

sistent  the  use  of  vegetables  should  be  restricted  until  the  looseness  of 
the  bowels  subsides.  Cooked  fruit  is  almost  always  well  digested,  but 
uncooked  apples,  pears,  and  plums  are  likely  to  cause  diarrhea. 
Pastry  and  cakes  should  be  excluded,  though  I  have  found  that  Hght 
loaf  gingerbread  taken  with  milk  agrees  very  well  with  many,  perhaps 
on  account  of  the  ginger  being  a  good  intestmal  antiseptic.  The  prep- 
aration called  MelHn's  Food,  taken  in  hot  milk,  often  relieves  the 
morning  headaches,  and  may  be  taken  at  other  times,  between  meals, 
when  the  patients  feel  weak  or  exhausted.  All  fermented  alcoholic 
liquors  should  be  avoided  and  only  spirits  allowed  in  moderation,  and 
never  on  an  empty  stomach. 

The  proper  medicinal  treatment  of  Graves'  disease  affords  one  of 
the  most  conclusive  proofs  of  the  gastro-intestinal  origin  of  the  malady. 

Thus,  the  heart  quiets  down  immediately  after  the  action  of  a  mer- 
curial cathartic.  I  have  repeatedly  known  the  pulse  to  fall  40  beats 
after  a  single  blue  pill  had  been  taken.  My  notes  on  this  point  are  as 
follows:  Whole  number  of  cases  with  goiter,  who  took  mercurial  lax- 
ative once  a  week  throughout  treatment,  18.  Improvement  in  all 
except  I ,  who  declined  to  take  it  on  account  of  the  effect  on  her  teeth ; 
whole  number  of  cases  without  goiter,  20,  and  rehef  failed  only  in  i 
case.  It  is  equally  noteworthy  that  the  beneficial  action  of  mercurial 
laxatives  is  not  restricted  to  its  first  employment,  but  continues  upon 
its  use  for  months  and  years,  the  patients  reporting  that  they  felt  better 
after  taking  it  throughout  their  entire  illness.  The  presence  of  diar- 
rhea instead  of  counterindicating  mercurial  laxatives,  is  reHeved  by 
them  with  far  more  certainty  than  by  any  astringents. 

The  only  explanation  why  a  mercurial  laxative  can  so  favorably 
affect  a  persistent  overaction  of  the  heart,  and  relieve  mental  depres- 
sion better  than  any  stimulant,  and  cahn  nervousness  and  tremor,  is 
that  mercurial  laxatives  are  among  our  best  established  intestinal  anti- 
septics. I  have  yet  to  meet  with  a  case  of  Graves'  disease  in  which 
their  administration  aggravated  any  condition  in  the  patient.  With 
most  patients  I  prescribe  the  5-gr.  blue  pill,  taken  at  night,  followed 
by  a  saline  in  the  morning.  It  is  very  common  for  the  patients  to  say 
that  they  feel  the  benefit  of  the  mercurial  more  on  the  second  day  than 
on  the  first  after  taking  the  dose.  To  many  patients  I  prescribe  the 
mercurial  twice  a  week,  while  with  others  once  a  week.  Occasionally 
castor  oil  seems  to  act  better  than  a  mercurial  cathartic.  This  can 
be  found  out  only  on  trial.  In  some  cases  of  insomnia  i  gr.  of  calo- 
mel with  2  teaspoonfuls  of  compound  Hcorice  powder,  taken  at  bed- 
time, acts  as  an  excellent  soporific.      Marked  general  weakness  does 


492  CLINICAL   MEDICINE 

not  contra-indicate  the  use  of  these  cathartics,  owing  to  their  counter- 
acting the  primary  cause  of  the  systemic  prostration. 

Gastric  flatulence  and  discomfort  are  symptoms  which  often  con- 
tinue to  be  very  obstinate  and  persistent.  The  whole  list  of  vegetable 
bitters  may  be  discarded,  including  nux  vomica  or  strychnin,  nor  are 
the  mineral  acids  of  much  use.  Pepsin  is  equally  disappointing  and 
likewise  charcoal.  Gastric  lavage  I  never  prescribe,  for  many  of  the 
patients  who  have  come  to  me  have  had  this  procedure  faithfully 
tried  before,  with  the  invariable  story  that  no  mucus  was  brought  away 
by  the  washing,  and  that  they  felt  worse  after  its  emplojnnent.  As 
it  is  a  constant  characteristic  of  Graves'  disease  that  its  various 
visceral  derangements  have  no  inflammatory  element  connected  with 
them,  the  failure  of  different  measures  often  used  in  other  forms 
of  gastric  disorders  is  not  surprising.  Resorcin  often  benefits  this 
flatulent  condition,  though  not  as  markedly  as  it  does  in  gastritis. 

Among  our  intestinal  antiseptics,  bismuth  must  always  take  the 
first  rank.  I  have  foimd  its  combination  with  phenol  derivatives 
especially  useful.  Such  preparations  as  lo  gr.  of  phenol  bismuth  or 
naphthol  bismuth,  with  the  same  quantity  of  sodium  benzoate  in 
two  capsules,  taken  an  hour  after  meals  and  on  retiring,  have 
been  administered  to  numerous  patients  with  benefit  for  months 
at  a  time. 

There  may  be  no  question,  also,  of  the  great  value  of  the  salicylates 
in  Graves'  disease,  as  both  the  sodium  salicylate  and  the  sodium  ben- 
zoate are  efficient  cholagogues.  I  have  been  accustomed  to  give  lo 
gr.  of  each,  in  capsules,  an  hour  after  meals,  in  the  treatment  of  mi- 
graine as  a  prophylactic. 

The  sodium  phosphate  in  quite  a  proportion  of  patients  seems  to 
assist  their  digestion,  taken  in  doses  of  |  dram  just  before  eating. 

Surgical  Treatment. — Of  recent  years  very  favorable  results  have 
been  reported,  particularly  by  the  Mayo  brothers,  of  Rochester,  Minn., 
of  the  curative  effects  of  a  partial  resection  of  the  thyroid  gland  in 
cases  of  exophthalmic  goiter.  While  I  do  not  doubt  the  reports  of 
such  favorable  results,  I  cannot  account  for  them.  The  partial  re- 
section of  the  liver  in  a  case  of  cirrhosis,  or  of  any  other  organ  of  the 
body  affected  by  organic  changes,  never  produces  either  amelioration 
or  cure.  Nor  can  I  see  how  such  a  procedure  could  be  of  benefit  in 
Graves'  disease.  In  advanced  or  severe  cases  of  this  complaint  any 
surgical  operation  is  dangerous.  Moreover,  we  should  have  statistics 
showing  the  permanence  or  otherwise  of  the  effects  of  such  surgical 
treatment. 


graves'  disease  493 

If  the  thyroid  gland  spontaneously  hypertrophies,  and  causes 
Graves'  disease  by  consequent  excess  of  its  secretion,  it  would  stand 
absolutely  alone  among  diseases.  No  gland  ever  secretes  anything 
spontaneously.  There  is  always  some  antecedent  cause  to  secretion, 
whether  in  the  blood  or  in  the  tissues.  Thus,  salivation  by  the  paro- 
tids does  not  happen  without  the  previous  presence  of  mercury  in  the 
blood.  But  what  is  the  antecedent  of  so-called  thyroidism  in  Graves' 
disease?  That  there  is  such  an  antecedent  in  Graves'  disease  we 
have  demonstrated  to  be  found  in  the  genesis  of  a  blood  poison  in 
the  intestines.  This  poison  may  or  may  not  cause  hypertrophy  of  the 
thyroid  gland,  and  hence  present  us  with  cases  of  Graves'  disease  with 
or  without  exophthalmic  goiter. 


CHAPTER  XIII 

DISEASES  CAUSED  BY  ANIMAL  PARASITES 

CESTODES,  OR  TAPEWORMS 

We  have  already,  in  the  article  on  Hydatids,  shown  how  widely 
dispersed  in  the  animal  vertebrate  kingdom  the  cestodes  or  tapeworms 
are  distributed.  But,  although  in  their  second  generation,  some  vari- 
eties of  them  may  grow  from  twenty  to  thirty  feet  in  length,  they 
rarely  produce  any  serious  symptoms,  and  their  presence  is  revealed 
to  the  patient  only  by  more  or  less  lengthy  portions  of  the  worm  being 
passed  by  the  bowels.  These  received  the  name  of  tapeworm  from 
their  resemblance  to  pieces  of  tape,  from  which,  however,  they  differ,  as 
they  are  divided  into  segments  whose  length  and  size  vary  in  different 
species.  These  segments  become  smaller  and  smaller  as  they  approach 
the  head  of  the  worm,  which  has  attached  itself  firmly  to  a  fold  of  the 
intestinal  mucous  membrane. 

It  is  not  until  the  head  itself  has  been  expelled  that  the  patient  can 
be  pronounced  free  from  this  parasite.  As  before  remarked,  different 
species  of  tapeworm  are  found  in  different  animals,  many  of  them  being 
rare  in  the  United  States,  where  the  commonest  form  comes  from  eating 
beef.  I  found  the  Taenia  saginata  very  common  in  Mediterranean 
countries,  from  the  practice  of  the  natives  eating  uncooked  meat.  This 
form  is  also  the  commonest  in  the  United  States.  Another  species, 
called  the  Taenia  soHum,  comes  from  pork,  and  is  prevalent  in  Germany 
from  the  consumption  there  of  sausages.  The  largest  of  tapeworms, 
however,  is  called  Bothriocephalus,  and  is  common  in  Finland  and 
Japan  from  eating  raw  fish. 

As  the  first  generation  of  these  parasites  consists  of  very  small 
sacs,  which  have  found  their  way  to  the  muscles  from  the  intes- 
tines, they  are  called  cestodes. 

One  form,  Taenia  larvo-punctata,  has  its  larvae  developed  in  butter- 
flies and  in  beetles.  A  curious  alhed  form  to  this  species  is  often  found  in 
shallow  pools  of  water,  when  the  full-grown  worm,  called  godius,  resem- 
bles, as  it  swims  in  the  water,  a  five  horsehair.  The  eggs  of  this  godius 
are  attached  to  each  other,  and  form  long  strings  wound  round  weeds 
in  the  side  of  the  pool,  looking  there  like  tufts  of  cotton.     As  they  exist 

494 


CESTODES,  OR    TAPEWORMS  495 

in  immense  numbers,  the  singular  survival  of  the  species  is  explained, 
for  that  survival  can  occur  only  by  a  single  egg  penetrating  and  devel- 
oping in  the  thigh  muscles  of  a  grasshopper.  This  can  happen  only 
when  the  pool  has  dried  up,  so  that  a  grasshopper  can  jump  upon  the 
place  and  thus  get  an  egg  attached  to  the  thigh.  As  these  insects,  in 
turn,  may  die  in  water,  the  larvai  of  the  godius  may  be  thus  set  free. 

Treatment  of  Tapeworm. — The  first  indication  on  this  subject  is 
prophylaxis.  This  is  done,  particularly  in  Germany,  by  a  well-organ- 
ized staff  in  the  abattoirs  of  the  large  cities,  which  inspects  the  car- 
casses of  hogs,  sheep,  and  beeves  for  the  discovery  in  meats  of  the 
cysticerci.  When  about  one  in  6  per  cent,  of  the  carcasses  of  hogs  are 
found  infected  the  pork  is  then  called  measly  from  its  appearance. 
Analogous  alterations  are  found  in  infected  beef  and  mutton.  Unfor- 
tunately, we  do  not  have  similar  inspections  made  in  the  United 
States  except  in  cases  of  cows  suspected  of  tuberculosis. 

The  eating  of  meat  infected  by  cestodes  leads  to  the  development 
and  growth  in  the  intestines  of  the  various  species  of  tapeworm. 
Although  the  full-grown  tapeworm  does  not  seriously  interfere  with 
the  health  of  the  persons  affected  by  them,  yet  the  knowledge  of  their 
presence  often  so  worries  them  that  they  become  very  apprehensive 
and  insist  upon  their  removal.  For  this  purpose  we  have  a  number  of 
remedies,  the  agent  most  commonly  used  being  the  ethereal  extract 
of  Filix  mas  or  male  fern.  To  secure  its  best  action,  the  patient 
should  live  upon  very  light  or  milk  diet  for  two  days,  and  then,  in  the 
morning,  on  a  fasting  stomach,  take  2  drams  of  the  ethereal  extract  of 
Filix  mas,  followed  in  two  hours  by  a  dose  of  5  gr.  of  calomel  with  40 
gr.  of  compound  jalap  powder.  When  the  bowels  have  acted  a  dihgent 
search  shoula  be  made  for  the  head  of  the  worm.  Meantime,  whether 
the  head  be  found  or  not,  what  has  been  brought  away  of  the  tapeworm 
should  be  burned,  and  not  thrown  down  the  water-closet,  because  the 
eggs  are  not  only  very  tenacious  in  their  vitality,  but  may  live  for  at 
least  twenty  days  outside  the  body  and  be  the  means  of  infecting  other 
animals.  We  have,  however,  other  agents  which  are  more  or  less 
effective  against  tapeworm,  the  chief  of  which,  in  my  experience,  are 
pumpkin  seeds.  Next  to  these  come  infusions  of  the  bark  of  the  root 
of  the  pomegranite.  In  taking  the  pumpkin  seeds,  3  or  4  oz.  should  be 
bruised  and  then  macerated  for  twelve  or  fourteen  hours.  The  entire 
quantity  should  be  taken,  followed  by  an  efficient  purge.  An  infusion 
of  the  bark  of  the  pomegranite  root  is  a  very  efficient  remedy — 3  oz. 
may  be  macerated  in  10  oz.  of  water  and  boiled  down  one-half.  The 
whole  quantity  may  be  given  in  divided  doses,  to  be  followed  in  an 


496  CLINICAL  MEDICINE 

hour  by  a  purge.  The  active  principle  of  the  root  pelletierin  is  now- 
much  employed.  It  is  given  in  doses  of  6  to  8  gr.  with  5  gr.  of  tannin, 
in  sweetened  water,  followed  in  an  hour  by  a  purge.  In  obstinate 
cases  we  may  try  a  combination  of  these  vermifuges — namely,  pome- 
granite  root,  I  oz.;  pumpldn  seeds,  i  oz.,  powdered  ergot,  i  dram,  and 
boiling  water,  10  oz.;  an  emulsion  of  i  dram  of  ethereal  extract  of 
Filix  mas,  made  with  acacia  powder,  2  min.  of  croton  oil  are  added. 
The  emulsion  and  infusion  should  be  mixed  and  taken  fasting  in  the 
morning.  It  is  well  in  all  cases  to  clear  the  intestines  previously  by 
I  oz.  of  Epsom  salts,  taken  for  two  mornings. 

HYDATIDS,  OR  ECHINOCOCCI 

Hydatids,  when  found  in  the  bodies  of  men  or  other  animals, 
appear  as  cysts  or  bags  of  fluid,  which  give  no  intimation  of  their  true 
origin.  These  cysts  may  be  very  large,  so  that  by  their  mere  mechan- 
ical presence  they  cause  dislocation  of  important  organs  of  the  body. 
It  is  only  by  the  prolonged  researches  of  pathologists  that  the  true 
nature  of  these  virtually  animal  parasites  was  demonstrated.  Be- 
cause their  origin  is  from  a  minute  worm,  attached  to  the  inner  folds 
of  the  intestine  of  a  dog,  these  worms  are  classed  among  the  tenia,  and, 
therefore,  belong  to  the  same  general  class  as  the  tapeworms,  whose 
parasitic  presence  is  so  wide  in  the  animal  kingdom.  As  tapeworms 
develop  to  such  an  extent  in  the  intestines  without  any  visible  ante- 
cedents they  were  at  first  ascribed  to  spontaneous  generation,  but  fur- 
ther researches  showed  that  most  animals  had  their  own  kind  of  tape- 
worms. It  was  at  this  stage  that  Von  Siebald  discovered  that  owls 
and  cats  had  the  same  kind  of  tapeworm,  and  he  inferred  that  this  was 
because  owls  and  cats  Hved  on  the  same  diet — namely,  mice.  There- 
upon he  examined  the  bodies  of  mice,  and  found  that  many  of  them 
were  infected  by  minute,  parasites,  which  lived  in  the  form  of  small  sacs 
in  their  bodies,  especially  their  muscles.  He,  therefore,  fed  dogs  with  the 
flesh  of  these  mice,  with  the  result  that  these  dogs  developed  in  their 
intestines  the  same  tapeworm  which  grew  in  owls  and  in  cats.  This 
was  a  notable  scientific  discovery,  because  it  estabHshed  the  great  law 
of  alternate  generation  in  the  animal  kingdom,  often  illustrated  in  our 
own  species,  where  children  frequently  resemble  their  grandparents 
more  than  their  parents.  In  this  case,  the  first  generation  was  a  little 
sac  in  the  muscles  of  a  mouse,  while  the  second  generation,  having  no 
resemblance  to  the  little  sac,  grows  into  a  long  tapeworm. 

We  are,  therefore,  now  better  enabled  to  understand  what  the  ori- 
gin of  hydatids  is.     They  begin  with  a  minute  worm,  found  only  in 


HYDATIDS,    OR    ECHINOCOCCI  497 

the  intestine  of  the  dog,  which  is  called  Taenia  echinococcus.  This  is 
a  tiny  cestode,  not  more  than  4  or  5  mm.  in  length,  consisting  of  three 
or  four  segments,  of  which  the  terminal  one  alone  is  mature,  and  has  a 
length  of  about  2  mm.  and  a  breadth  of  0.6  mm.  The  head  is  small 
and  provided  with  four  sucking  disks  and  a  rostellum  with  a  double 
row  of  booklets,  which  are  closely  adherent  to  the  inner  lining  of  the 
small  intestine  of  the  dog.  The  ripe  segment  contains  about  5000 
eggs,  which  attain  their  development  in  the  soUd  organs  of  the  infected 
animal. 

The  Httle  six-hooked  embryo,  fed  from  the  eggshell  by  digestion, 
burrows  through  the  intestinal  wall  and  reaches  the  peritoneal  cavity 
or  the  muscles.  It  may  enter  the  portal  vessels  and  be  carried  to  the 
liver.  It  may  enter  the  systemic  vessels  and  be  distributed  to  any 
part  of  the  body.  It  will,  therefore,  cause  symptoms  according  to 
where  it  is  lodged;  thus,  one  of  the  most  serious  of  its  results  is  when  a 
hydatid  is  lodged  and  grows  in  the  brain,  causing  then  all  the  symptoms 
of  brain  tumor.  But  the  commonest  place  of  development  is  in  the 
liver. 

Once  having  reached  its  destination,  it  undergoes  the  following 
changes:  the  booklets  disappear,  and  the  Httle  embryo  is  gradually 
converted  into  a  small  cyst,  which  presents  two  distinct  layers,  an 
external,  laminated,  cuticular  membrane  or  capsule,  and  an  internal, 
granular,  parenchjnnatous  layer,  the  endocyst.  The  Httle  cyst,  or 
vesicle,  contains  a  clear  fluid.  There  is  more  or  less  reaction  in  the 
neighboring  tissues,  and  the  cyst  has,  in  time,  a  fibrous  investment. 
When  this  primary  cyst  has  attained  a  certain  size  buds  develop  from 
the  parenchymatous  layer,  which  are  gradually  converted  into  cysts, 
presenting  a  structure  identical  with  that  of  the  original  cyst. 

We  are  particularly  interested  in  the  inner  or  parenchymatous 
layer,  because  from  it,  by  a  process  very  similar  to  budding,  spring  the 
numerous  daughter-cysts,  which  are  constructed  Hke  the  parent  cyst, 
and  may,  if  set  free,  produce  just  the  same  results. 

In  the  United  States  an  original  case  of  hydatids  is  very  rare.  Out 
of  241  cases  reported  by  Lyon  (in  1902)  only  i  was  a  native  American. 
In  my  own  hospital  experience  I  met  with  only  i  case,  in  a  German 
woman,  who  appHed  for  admission  on  account  of  intractable  vomiting. 
On  examination  of  the  vomitus  a  number  of  the  booklets  of  the  echino- 
cocci  were  found.  In  her  case  this  hydatid  had  grown  in  her  Hver  until, 
by  an  inflammatory  process,  it  adhered  to  and  perforated  into  the 
stomach.  The  only  other  cases  which  I  have  seen  were  in  two  ladies 
who,  while  in  Europe,  were  accustomed  to  caress  and  fondle  their  pet 

32 


498  CLINICAL   MEDICINE 

dogs.  They  both  developed  hydatids  in  the  liver.  One  of  them 
was  cured  by  incision  and  emptying  of  the  sac,  but  in  the  other  case 
an  abscess  formed  and  burst  externally. 

The  prevalence  of  this  infection  is  greatest  in  countries  like  Ire- 
land, where  dogs  constantly  Hve  in  the  same  huts  with  their  owners, 
and  also  in  AustraHa,  where  dogs  are  used  for  sheep  herding. 

Treatment. — The  only  treatment  is,  first,  to  settle  the  diagnosis 
by  aspirating  some  of  the  Hquid  of  the  tumor  and  finding  in  it  the  hook- 
let  of  the  echinococcus.  The  sac  should  then  be  freely  opened  and 
treated  on  the  ordinary  principles  of  surgery. 

TRICHINIASIS 

This  singular  invasion  of  the  muscular  tissues  of  the  human  body 
by  the  embryos  of  the  Trichina  spiraHs,  a  worm  originally  derived  from 
swine,  occurs  in  the  United  States  among  German  immigrants,  who  are 
accustomed  to  eat  ham  or  sausages  which  are  not  thoroughly  cooked. 
I  have  met  with  a  number  of  such  cases,  and  in  every  one  of  them  the 
diagnosis,  which  otherwise  might  have  been  difficult,  was  suggested 
by  the  remarkable  increase  of  the  eosinophiles  among  the  white  cor- 
puscles of  the  blood.  Normally,  the  eosinophiles  do  not  rise  much 
above  2  per  cent,  of  the  leukocytes,  but  in  my  cases  the  proportion  was 
between  20  and  30  per  cent.  Cases  have  been  reported  of  the  eosino- 
philes being  over  60  per  cent,  of  the  leukocytes.  Why  the  remarkable 
increase  in  this  variety  of  leukocytes  should  occur  so  specifically  in  this 
infection  is  unknown.  It  is  possible  that  it  is  due  to  poison  secreted 
by  the  worm  embryos  in  their  transit  from  the  small  intestine  to  the 
muscles. 

This  parasite  was  identified  by  Tiedman  in  1822  and  by  Hilton  in 
1832,  and  first  named  by  Richard  Owen.  As  above  remarked,  its 
original  habitat  is  in  pork,  which  in  Germany  leads  to  official  inspec- 
tion of  all  such  meat  in  the  abattoirs. 

This  worm  first  develops  in  the  small  intestine,  and  may  there  give 
rise  to  its  first  symptoms  which,  in  some  cases,  may  be  so  severe  from 
the  accompanying  diarrhea  and  vomiting  as  to  suggest  cholera  morbus. 
While  sojourning  in  the  small  intestine  the  female  worm  produces 
crowds  of  embryos,  which,  by  means  of  the  hooks  about  their  mouths, 
penetrate  the  walls  of  the  intestine  and  make  their  way  to  the  muscular 
tissues,  where  these  larval  forms  grow  and  usually  become  encysted. 
It  is  due  to  their  presence  in  the  muscular  system  that  the  symptoms 
of  the  disease  develop.  These  at  first  might  easily  be  mistaken  for 
muscular  rheumatism,  because  the  muscles  become  tender  both  on 


ASCARIDES  499 

movement  and  on  pressure.  When  this  infection  is  at  all  general  the 
symptoms  become  serious;  thus,  implication  of  the  diaphragm  may 
directly  occasion  severe  dyspnea.  Fever  is  a  very  common  accompani- 
ment, which  occasionally  is  so  intermittent  as  to  suggest  malaria. 
Ordinarily,  however,  the  symptoms  appear  more  Uke  those  of  typhoid 
fever,  causing  great  prostration,  with  dryness  of  the  tongue  and  febrile 
pulse.  Examination,  of  the  blood  will  at  once  settle  the  diagnosis. 
The  further  course  of  the  fever  is  very  prolonged,  leading  to  emaciation 
and  death  from  intercurrent  comphcations.  The  excision  of  a  piece  of 
muscular  tissue  during  life,  whether  from  the  deltoid  or  the  gluteus, 
will  reveal  the  presence  of  the  encysted  trichinae. 

Treatment  is  of  no  avail  during  the  early  stages,  while  the 
worms  infest  the  small  intestine,  giving  rise  to  the  symptoms  which  we 
have  described.  Then  a  dose  of  turpentine,  |  oz. ,  combined  with  i  oz.  of 
castor  oil  and  5  gr.  of  thymol,  should  be  given  on  an  empty  stomach. 
This  may  be  repeated  once  a  week  for  three  weeks.  The  worms  may 
be  discovered  in  the  stools,  which  should  be  spread  on  a  glass  plate 
or  black  background  and  examined  with  a  low-power  lens,  when  the 
trichinae  are  seen  as  small  ghstening  silvery  threads.  For  the  encysted 
embryos  in  the  muscles  themselves  we  have  no  treatment. 

Dr.  R.  C.  Kemp,  of  New  York,  has  told  me  that  he  has  cured  a 
case  of  trichina  by  persevering  in  doses  of  urotropin,  from  40  to  80  gr. 
a  day,  which  killed  the  par  sites  in  situ. 

ASCARIDES 

There  remains  for  our  consideration  two  forms  of  intestinal  worms, 
the  Ascaris  lumbricoides,  or  long  round  worms,  and  the  Oxyuris  ver- 
micularis,  or  pin- worms. 

They  differ  altogether  from  the  tenia,  in  that  their  Hfe-history  is 
exclusively  in  the  intestine.  Both  forms  may  infect  grown  persons, 
but  the  rule  is  that  they  occur  in  children.  The  round  worms  are 
pointed  at  each  end,  and  usually  of  a  reddish  color.  Ordinarily,  they 
are  either  single  or  few  in  number,  but  they  may  occur  in  such  numbers 
as  to  produce  a  great  variety  of  troublesome  symptoms,  otherwise 
the  patient  may  not  be  aware  of  their  presence  until  he  passes  one  from 
his  bowels.  The  usual  seat  of  development  is  in  the  upper  part  of 
the  small  intestine,  but  many  cases  are  reported  of  their  wandering 
upward  into  the  pharynx  or  even  into  the  Eustachian  tube.  When 
they  occur  in  large  numbers  in  the  intestines  they  may  produce  a  great 
variety  of  nervous  symptoms,  such  as  twitching  of  the  muscles  during 
sleep  or  picking  of  the  nose  and  grinding  of  the  teeth.      Parents  are 


500  CLINICAL  MEDICINE 

apt  to  ascribe  many  forms  of  illness  to  their  presence,  but  ordinarily 
they  occasion  very  few  really  morbid  symptoms. 

Treatment. — Almost  any  active  purgative,  especially  calomel  and 
castor  oil,  will  dislodge  these  worms,  but  the  specific  for  them  is  santo- 
nin. Santonin  may  be  given,  mixed  with  sugar,  in  doses  of  from  J  to  i 
gr.  for  a  child  and  2  or  3  gr.  for  an  adult,  followed  by  calomel  or  a, 
saline  purge.  The  dose  may  be  given  for  three  or  four  days.  An 
unpleasant  consequence  which  sometimes  follows  the  administration 
of  this  drug  is  xanthopsia,  or  yellow  vision,  but  which  is  of  no  serious 
import,  for  it  soon  disappears. 

OXYURIS  VERMICULARIS  (PIN-WORMS) 
These  worms  are  very  common  sources  of  annoyance  to  children. 
Their  habitat  is  in  the  rectum,  but  I  have  known  of  their  extending 
throughout  the  colon  in  the  case  of  a  man.  In  children  they  are  apt  to 
occa^on  much  itching  about  the  anus,  especially  at  night,  and  thus 
interfere  with  sleep.  Their  treatment  is  entirely  local,  consisting  of 
enemata,  which  should  be  given  the  child  while  lying  on  its  back  and 
with  the  hips  elevated.  The  enemata  may  consist  simply  of  normal 
saline,  a  teaspoonful  of  salt  to  a  pint  of  water.  Much  the  most  effective 
agent,  in  my  experience,  is  to  make  an  infusion  of  |  oz.  of  pieces  of 
quassia  wood  to  the  pint  of  water.  Medicines  or  vermifuges  by  the 
mouth  need  not  be  administered. 

ANKYLOSTOMIASIS  (HOOKWORM  DISEASE) 

This  disease,  which  is  caused  solely  by  a  worm  which  infects  the 
intestine,  is  one  of  the  widest  spread  affections.  It  prevails  in  the 
southern  districts  of  the  United  States,  in  parts  of  Europe,  as  in 
Germany,  Belgium,  France,  and  Hungary,  particularly  among  miners, 
and  especially  in  Porto  Rico,  India,  and  the  Philippines.  Recent 
studies  of  its  prevalence  in  Porto  Rico  have  shown  that  the  larvae  of 
this  worm  first  creep  up  the  leg  below  the  knee,  often  causing  a  trouble- 
some itching  of  the  skin  which  they  traverse,  producing  at  first  a  vesicu- 
lar eruption  and  then  pustules  form  with  a  sticky  exudate,  sometimes 
with  much  swelling  of  the  skin,  and  then  take  a  route  through  the  blood 
until  they  reach  the  intestines,  where  they  develop. 

No  other  infection  is  known  which  takes  such  a  specific  and  circuit- 
ous route  in  its  course.  There  are  two  chief  forms,  the  Ankylostoma 
duodenale,  the  Old  World  species,  and  the  Necator  americanus,  the  New 
World  species.  The  ankylostoma  is  a  small  cylindric  nematode,  the 
male  about  10  mm.  and  the  female  from  10  to  18  mm.  in  length.     The 


ANKYLOSTOMIASIS    (HOOKWORM   DISEASE)  50I 

mouth  has  chitinous  plates,  and  is  provided  with  two  pairs  of  sharp, 
hook-shaped  teeth  with  which  they  pierce  the  mucosa  of  the  bowel. 
The  male  has  a  prominent,  umbrella-like  caudal  expansion. 

The  disease  is  propagated  by  numerous  eggs  of  the  worm,  and  the 
larvae,  after  escaping  from  the  eggs,  may  live  for  months  in  the  mud  or 
water  of  the  mines,  and  they  pass  through  a  series  of  moults  before 
they  reach  what  is  called  the  ripe  stage.  At  this  time,  besides  great 
tenacity  of  life,  they  show  a  marked  tendency  to  wander.  The  num- 
bers of  these  eggs  is  extraordinary,  estimated  at  4,000,000  in  a  badly 
infected  person,  and  they  are  readily  detected  in  the  intestinal 
passages. 

The  route  from  the  skin  to  the  intestine,  first  demonstrated  by  Looss 
and  confirmed  by  many  others,  is  from  the  veins  to  the  heart  and  thence 
to  the  lungs,  in  which  they  escape  from  the  pulmonary  vessels,  pass  up 
the  bronchi  and  trachea,  and  so  to  the  gullet,  stomach,  and  intestines. 

Pathologic  anatomy  shows  that  it  is  the  upper  part  of  the  intestine, 
and  particularly  the  jejunum,  which  is  affected  by  these  blood-suck- 
ing worms,  who  also,  hke  leeches,  seem  to  secrete  a  substance  which 
prevents  the  coagulation  of  the  blood.  The  clinical  symptoms  are 
then  those  of  anemia  from  chronic  hemorrhage  with  fatty  degeneration. 
The  injury  to  the  mucous  membrane  of  the  intestine  may  also  allow 
auto-intoxication  to  occur. 

Very  naturally,  in  localities  where  the  hookworm  disease  prevails, 
may  be  found  many  individuals  suffering  from  all  the  constitutional 
effects  of  chronic  anemia,  such  as  incapacity  for  any  continued  exertion. 
In  children  especially  the  normal  growth  may  be  much  interfered  with, 
while  the  hemoglobin  falls  from  40  to  50  per  cent,  and  in  several  cases 
75  per  cent.  The  patients  then  become  incapable  of  any  exertion, 
and  have  to  take  to  their  beds,  often  dying  with  the  symptoms  of  pure 
asthenia. 

Digestive  disturbances  not  uncommonly  occur,  accompanied,  as  in 
some  cases  of  chlorosis,  with  perversions  of  appetite,  so  that  they  eat 
earth,  paper,  or  clay;  the  dirt-eaters  of  the  Southern  States  are  all  sub- 
ject to  the  hookworm  disease. 

The  diagnosis  of  this  complaint  is  easy,  by  finding  the  eggs  in  the 
feces.  The  eggs  are  characteristic  structures,  usually  containing  four 
or  eight  segments,  sometimes  the  complete  embryo  nearly  ready  to 
burst  its  shell. 

One  of  the  most  important  prophylactic  measures  is  to  wear  shoes 
and  stockings,  but  in  all  warm  countries  this  is  a  very  difficult  pro- 
cedure to  adopt  for  children. 


502 


CLINICAL   MEDICINE 


Treatment. — We  have  one  specific  for  this  dangerous  infection, 
that  is  thymol.  A  saUne  purgative  should  be  taken  first  at  night,  of 
which  the  best  is  the  sulphate  of  magnesia.  The  thymol  should 
be  graduated  according  to  the  age  of  the  patient,  the  dose  for  a  child 
under  five  being  7  gr.,  divided  into  two  capsules.  The  next  morning 
after  having  taken  the  purgative  the  night  before,  one  capsule  of 
thymol  may  be  taken  at  6  a.  m.  and  the  second  at  8  a.m.;  two  hours 
afterward  the  sahne  purgative  of  the  night  before  should  be  repeated. 
For  adults  the  thymol  has  to  be  given  in  large  doses,  preferably,  there- 
fore, in  capsules  which  may  contain  10  gr.  each,  and  may  be  taken  at 
intervals  of  ten  minutes,  until  60  gr.  have  been  taken;  two  hours  after 
the  last  dose  the  saline  purgative  should  be  again  taken.  This  treat- 
ment should  be  carried  out  on  one  day  of  each  week,  until  the  patient 

is  cured. 

BALANTIDIUM  COLI 

This  parasite  is  of  several  species  which  infest  the  intestines,  the 
most  important  of  which  is  the  Balantidium  coli,  which  is  responsible 
for  dysenteric  symptoms,  notably  in  the  Philippines,  as  reported  by 
Musgrave.  It  is  oval  in  form,  70  to  100  mm.  long,  and  50  to  70 
mm.  broad,  which,  although  it  may  penetrate  the  mucosa  and  submu- 
cosa,  yet  does  not  extend  outside  of  the  bowel,  though  it  may  be  the 
cause  of  pronounced  dysenteric  symptoms. 

The  treatment  of  this  parasite  should  be  that  of  amebic  dysentery, 
with  full  doses  of  ipecacuanha.  Thymol,  given  in  two  capsules  of  5  gr. 
each  on  rising  in  the  morning,  may  also  be  tried. 

DRACONTIASIS   (GUINEA-WORM  DISEASE) 

This  parasitic  worm  enters  the  system  by  drinking  water  which 
contains  it.  While  it  prevails  widely  in  Africa,  it  is  also  reported  in 
India,  and  even  in  the  United  States,  doubtless  as  a  foreign  importa- 
tion. Cases  have  been  reported  in  Philadelphia  and  elsewhere  in  our 
country,  so  that  it  must  now  be  admitted  as  a  naturalized  species. 

When  it  has  entered  the  stomach  it  traverses  the  small  intestine, 
and  after  an  uncertain  sojourn  there  it  penetrates  the  tissues,  and  may 
be  felt  under  the  skin,  like  a  bunch  of  strings,  then  proceeding  down 
the  leg,  until  it  reaches  the  feet;  there  it  forms  a  vesicle,  in  which  its 
head  protrudes.  When  recognized  it  has  to  be  very  carefully  extracted 
and  wound  round  a  smooth  piece  of  wood,  like  a  pencil,  care  being 
taken  not  to  break  it  until  it  is  all  drawn  out,  because  if  broken  it 
sets  up  serious  inflammation. 

Treatment. — Free  doses  of  asafetida  are  said  to  destroy  the  worm. 


OTHER    NEMATODES  503 

FILARIASIS 

There  are  various  kinds  of  filaria;  one  form  of  filariasis,  the 
Filaria  bancrofti,  has  already  been  referred  to  under  the  head  of 
Chyluria.     (See  page  443.) 

There  is,  however,  a  form  that  appears  only  in  the  day,  and  that 
is  the  Filaria  diuma.     This  form,  however,  is  rare. 

Similar  filaria,  such  as  Filaria  pcrstans,  have  been  described,  but 
are  rare  except  in  certain  countries.  Daniels  and  Ozzard  have  shown 
the  extraordinary  prevalence  of  such  filaria  among  the  aborigines  in 
British  Guiana,  where  they  estimate  that  58  per  cent,  of  the  aborigines 
are  infected. 

OTHER  NEMATODES 

Under  the  head  of  animal  parasites,  we  need  refer  only  cursorily 
to  a  variety  mentioned  in  medical  literature,  of  which  all  are  rare  in 
this  country. 

Osier  mentions  some  of  the  less  important  parasitic  worms,  among 
which  are  the  Filaria  loa,  a  cyhndric  worm  of  about  3  cm.  length,  whose 
habitat  is  beneath  the  conjunctiva.  It  has  been  found  on  the  West 
African  coast,  in  Brazil,  and  in  the  West  Indies.  Filaria  lentis  has  been 
found  in  the  crystallized  lens  of  the  eye,  three  specimens  having  been 
found  together  there.  Filaria  labialis  is  another  kind  found  in  a  pus- 
tule in  the  upper  lip.  Filaria  hominis  oris  has  been  described  by  Leidy 
as  occurring  in  the  mouth  of  a  child.  Filaria  bronchiahs  occasionally 
develops  in  the  trachea  and  bronchi.  This  parasite  has  been  seen  in 
a  few  cases  in  the  bronchioles  and  in  the  lungs.  There  is  no  evidence 
that  it  eve:"  produces  an  extensive  verminous  bronchitis  similar  to  that 
which  has  been  described  in  dogs. 

Trichocephalus  Dispar  (Whip-worm). — This  parasite  is  not  infre- 
quently found  in  the  cecum  and  large  intestine  of  man.  It  measures 
from  4  to  5  cm.  in  length,  the  male  being  somewhat  shorter  than  the 
female.  The  worm  is  readily  recognized  by  the  remarkable  difference 
between  its  anterior  and  posterior  portions.  The  former,  which 
forms  at  least  three-fifths  of  the  body,  is  extremely  thin  and  hair-hke 
in  contrast  to  the  thick  hinder  portion  of  the  body,  which,  in  the  female, 
is  conical  and  pointed,  and  in  the  male  more  obtuse  and  usually  rolled 
like  a  spring.  The  eggs  are  oval,  lemon  shaped,  .05  mm.  ui  length, 
and  each  is  provided  with  a  button-like  projection. 

The  number  of  the  worms  found  is  variable,  as  many  as  a  thousand 
having  been  counted.  It  is  a  widely  spread  parasite.  In  parts  of 
Europe  it  occurs  in  from  10  to  30  per  cent,  of  all  bodies  examined,  but 


504  CLINICAL  MEDICINE 

in  the  United  States  it  is  not  so  common.  In  285  West  Indian  workers 
at  Panama,  Darling  found  46  per  cent,  infected.  It  is  possible,  he 
thinks,  that  these  parasites  play  a  role  in  amebic  dysentery,  the 
lesions  of  which  begin  at  the  exact  location  of  the  points  of  their  at- 
tachment. The  trichocephalus  rarely  causes  symptoms.  French  and 
Boycott  found  ova  in  40  of  500  Guy's  Hospital  patients.  They  found 
no  etiologic  relationship  of  the  parasite  to  appendicitis.  Several 
cases  have  been  reported  in  which  profound  anemia  has  occurred  in 
connection  with  this  parasite,  usually  with  diarrhea.  Enormous  num- 
bers may  be  present,  as  in  Rudolph's  case,  without  producing  any 
symptoms. 

The  diagnosis  is  readily  made  by  the  examination  of  the  feces,  which 
contains,  sometimes  in  great  abundance,  the  characteristic  lemon- 
shaped,  hard,  dark-brown  eggs. 

Strongyloides  Intestinalis. — This  parasite  was  discovered  in  1876 
by  Normand,  and  is  the  same  as  was  formerly  described  as  Anguillula 
stercorahs  and  Rhabdonema  intestinaUs.  It  is  a  common  parasite 
in  tropical  diarrhea,  particularly  in  Cochin  China.  It  is  foimd  in  about 
3  per  cent,  of  the  medical  patients  in  the  Isthmus  of  Panama,  and  in 
from  20  to  30  per  cent,  of  the  patients  in  the  insane  division.  When  in 
large  numbers  they  cause  diarrhea,  but  from  his  studies  there  Darling 
concludes  that  they  are  not  the  cause  of  severe  diarrhea,  though  they 
may  produce  moderate  anemia.  The  mother  worm  burrows  in  the 
mucous  membrane  and  deposits  ova.  The  parasite  is  found  in  the 
upper  part  of  the  small  intestine.  They  are  met  with  occasionally 
in  temperate  regions. 

PARASITIC  ARACHNIDS 

Scabies. — Under  the  head  of  arachnid  insects  we  would  mention 
the  acarus,  because  of  the  familiar  scabies  or  itch  so  common  in 
schools  and  institutions. 

It  produces  so  much  itching  that  the  whole  body  may  be  covered 
with  marks  from  the  effects  of  the  scratching. 

I  have  one  remedy  for  this  which  is  both  rapid  and  efficacious. 
The  remedy  is  prepared  by  boiling  i  part  of  quick-lime  with  2 
parts  of  sublimed  sulphur  in  10  parts  of  water  until  the  two  are  per- 
fectly united.  During  the  boiling  it  must  be  constantly  stirred  with  a 
stick  of  wood,  and  when  the  sulphur  and  lime  have  combined  the  fluid 
is  to  be  decanted  and  kept  in  a  well-stoppered  bottle.  A  pint  of  the 
Hquid  is  sufficient  for  the  cure  of  several  cases.  It  is  enough  to  wash 
the  body  well  with  warm  water,  and  then  to  rub  the  liquid  into  the 


PARASITIC    INSECTS  505 

skin  for  half  an  hour.  As  the  fluid  evaporates,  a  layer  of  sulphur  is 
left  upon  the  skin,  and  during  the  half-hour  the  acarus  is  killed  and  the 
patient  cured.  It  is  only  needful  then  to  wash  the  body  well  and  to 
wear  clean  clothes.  The  chief  point  in  this  plan  is  the  ready  absorp- 
tion of  the  remedy,  and  consequently  the  more  certain  and  quick 
destruction  of  the  insect  by  using  sulphur  in  a  fluid  form. 

This  application  is  equally  efficacious  against  the  ticks,  popularly 
called  jiggers,  in  the  Southern  States.  These  insects  burrow  under  the 
skin  and  produce  intense  itching. 

The  Dermacentor  occidentalis  is  present  in  the  Northwestern  States, 
from  California  to  Montana.  The  bites  may  cause  severe  lymphan- 
gitis. It  appears  to  be  the  medium  of  transmission  of  the  Rocky 
Mountain  spotted  fever  already  alluded  to. 

PARASITIC   INSECTS 

The  Pediculus  capitis,  or  common  louse,  infests  persons  who  are 
unclean  m  their  habits,  particularly  children.  Their  eggs  are  com- 
monly known  under  the  name  of  nits.  To  eradicate  them  the  hair 
should  be  cut  short,  and  the  head  and  other  hairy  parts  of  the  body 
should  be  rubbed  with  a  lotion  composed  of  3  oz.  of  cologne  with  ^  gr. 
of  corrosive  sublimate,  or  carbolic  acid  may  be  used,  in  the  propor- 
tion of  I  dram  to  the  pint  of  lime-water  liniment,  with  the  addition  of 
I  dram  of  oil  of  cinnamon. 

Pulex  irritans,  or  the  common  flea,  is  a  universal  pest  in  Asiatic 
coimtries,  and,  as  we  have  remarked,  is  the  great  agency  for  the  dis- 
semination of  the  pestis  or  plague.  I  was  once  obliged,  on  accoimt  of 
a  great  rain,  to  pass  the  night  in  a  peasant's  house  in  Mount  Lebanon, 
where  I  could  not  sleep  a  wink  all  night  from  the  bites  of  fleas.  The 
next  morning  I  was  simply  covered  with  the  consequent  eruption,  which 
caused  a  slight  fever.  In  that  country  a  powder,  made  from  some  vege- 
table substance,  is  sprinkled  in  the  bed,  which  is  probably  the  Actaea 
spicata  or  baneberry.  The  next  morning  the  fleas  are  found  benumbed 
by  it,  so  that  they  can  be  readily  collected  and  destroyed. 

Some  species  of  flies  also  become  very  troublesome  by  their  inva- 
sions. The  ova  of  the  blue-bottle  fly  may  be  deposited  in  the  nostrils, 
the  ears,  or  the  conjunctiva.  This  invasion  rarely  takes  place  unless 
the  mucous  membrane  of  these  regions  is  the  seat  of  disease. 

Liquids  should  not  be  injected  into  the  nose,  owing  to  the  danger  of 
infecting  the  Eustachian  tubes  which  open  into  the  pharynx  on  a  level 
with  the  floor  of  the  posterior  nares.  I  have  seen  a  case  of  total 
deafness  caused  by  a  neglect  of  this  precaution.     In  our  article  on 


5o6  CLINICAL  MEDICINE 

Chronic  Coryza  we  have  spoken  of  a  powder  being  blown  into  the  nose 
by  an  insufflator  which  contains  8  gr.  of  aristol,  12  gr.  of  salol,  and  4 
drams  of  subcarbonate  of  bismuth.  A  quantity,  such  as  would  cover 
a  ten-cent  piece,  may  then  be  put  in  the  scoop  of  the  insufflator  and 
blown  as  a  fine  smoke  into  all  parts  of  the  nose,  the  mouth  meantime 
being  kept  wide  open. 

The  larvae  of  different  species  of  flies  may  either  be  swallowed,  and 
produce  disorders  of  the  intestines,  or  infect  the  skin,  with  the  result 
of  various  cutaneous  manifestations.  Such  cases  are  reported  from 
every  country  in  the  world,  from  Russia  to  South  America,  and  should 
be  treated  by  local  applications,  varying  according  to  the  nature  of  the 
case. 

AFFECTIONS  FROM  CATERPILLARS 

In  this  country  the  brown-tail  moth  when  it  abounds  in  any  local- 
ity, particularly  in  New  England,  sheds  its  barbed  hairs,  which  then 
come  in  contact  with  the  skin,  producing  severe  itching  and  eruption, 
even  being  mistaken  for  small-pox.  Similar  affections  are  reported 
from  Europe,  especially  in  England,  from  the  yellow-tailed  moth,  and 
from  the  procession  caterpillar  in  Switzerland,  where  its  prevalence 
makes  some  districts  uninhabitable. 


CHAPTER    XIV 


DRUG   HABITS 


One  of  the  most  unwelcome  dangers  which  may  occur  to  a  physician 
when  he  prescribes  a  medicine  as  a  remedy  is  that  the  patient  may  be- 
come addicted  to  it  and  form  a  whohy  ruinous  drug  habit.  He  should, 
therefore,  clearly  understand  what  it  is  in  each  medicine  which  leads 
to  the  formation  of  such  a  habit;  only  thus  will  he  perceive  where  his 
responsibihty  begins  and  where  it  ends  in  ordering  a  person  to  have 
recourse  to  the  drug. 

Opium. — We  begin,  therefore,  with  the  most  insidious  and  most 
disastrous  of  drugs  when  the  unfortunate  person  has  become  enslaved 
by  it,  and  that  is  opium.  Few  persons  understand  what  it  is  in  opium, 
well  designated  by. the  ancients  as  the  great  gift  of  God  for  alleviating 
suffering,  which  may  in  time  become  an  irremovable  curse.  Its  dan- 
gers all  lie  in  its  seductive  attractiveness. 

Thus,  a  man  may  arrive  at  the  stage  when  he  takes  laudanum  not 
as  a  medicine,  but  as  a  drink;  that  done,  soon  a  sense  of  intense  interest 
is  awakened  in  him  similar  to  that  of  an  amateur  fisherman  when  he 
gets  a  strong  bite.  All  fishermen  know  that  every  concern  in  life  is 
displaced  for  the  time  by  that  pull  on  their  line.  At  first  he  scarcely 
knows  what  his  laudanum-bom  interest  is  about.  But  soon  a  crowd 
of  thoughts  arrive,  bringing  with  them  the  pleasing  assurance  that  to 
produce  such  a  succession  of  splendid  ideas  this  thinker,  at  any  rate, 
owns  a  first-class  brain.  Up  he  ascends,  as  if  to  take  a  seat  on  a  cloud, 
where  he  can  serenely  look  down  on  this  poor  mundane  sphere,  feeling 
himself  quite  above  its  fussy  littleness.  Such  conditions  are  graphic- 
ally described  by  De  Quincy,  in  his  "Confessions  of  an  English  Opium 
Eater,"  and  we  refer  the  reader  to  that  classic  book. 

As  might  be  inferred,  the  man  is  all  the  while  centered  on  the  crea- 
tions of  his  own  imagination,  and,  therefore,  the  opium  eater  is  solitary 
and  dislikes  interruption  by  others;  but,  after  the  effect  has  passed  off, 
it  is  succeeded  by  a  sense  of  horrible  vacancy,  sometimes  referred  to 
the  pit  of  the  stomach,  which  causes  a  restlessness  that  nothing 
will  reheve  but  more  opium.  So  naturally,  but  so  characteristically, 
is  his  subsequent  course  that  in  time  he  becomes  styled  an  opium  fiend, 

507 


5o8  CLINICAL  MEDICINE 

from  long  living  in  an  unreal  world,  and  becomes  transformed  into 
the  most  all-romid  liar  in  the  land,  the  very  embodiment  of  un ve- 
racity. One  of  them  victimized  me  with  a  loan  that  he  might  go  and 
close  the  eyes  of  his  dying  mother,  when  her  eyes  needed  no  such  closing 
for  years  afterward.  Another  sent  from  a  Western  city  to  his  wife  a 
telegram,  which  purported  to  come  from  an  undertaker  demanding 
money  to  pay  for  shipping  his  body  home;  this  money  when  it  came 
he — and  unfortunately  no  undertaker — pocketed  and  then  went  his 
way.  I  have  had  such  fellows  tell  me,  with  tears  in  their  eyes,  that 
their  chains  had  been  broken  the  night  before  in  answer  to  their 
earnest  prayers,  when  I  could  see  that  they  had  taken  a  dose  that 
same  hour.  And  so  their  deterioration  progresses  until  all  sense 
of  honor  is  gone  and  they  sink  below  that  last  refuge  of  self-respect — 
shame. 

Alcohol. — The  next  specimen  is  a  man  who,^if  he  is  in  a  prohibition 
town,  goes  to  a  drug  store  and,  with  a  knowing  wink,  asks  for  "spiritus 
frumenti,"  vulgarly  known  as  whisky.  It  first  makes  him  smile,  and 
soon  he  shows  that  not  so  much  his  thoughts  as  his  emotions  are 
excited.  As  it  is  not  natural  for  a  man  to  keep  his  feelings  to  himself, 
but  rather  to  share  them  with  others,  the  alcohol  taker  contrasts  with 
the  opium  taker  in  being  very  sociable.  The  usually  reserved  man  ad- 
mits people  into  his  confidence  and  talks  familiarly  with  everybody 
present.  When  a  number  are  sharing  their  drinks  and  feelings  to- 
gether with  laugh  and  song,  the  swift  flow  of  emotions  may  unhappily 
strike  some  rock,  which  so  violently  deflects  the  stream  that  heads  col- 
Hde  and  the  scene  ends  in  a  general  row.  Other  developments  are 
too  familiar  to  detain  us,  as  our  present  object  is  rather  to  note  the  char- 
acteristic workings  of  alcohol  on  the  mind.  We  all  know  what  the 
confirmed  drunkard  becomes,  but  not  till  the  judgment  day  will  the 
whole  story  be  known  of  the  griefs  and  tears  of  the  innocent  ones 
whom  the  drunkard  made  to  suffer  while  he  was  here. 

One  of  the  drugs  which  is  most  striking  in  its  effects  is  hashish, 
or  Cannabis  indica,  largely  taken  in  Asiatic  countries,  where  I  used 
myself  to  meet  its  votaries.  Its  chief  pecuHarity  is  to  make  one  be- 
Heve  with  all  his  might  whatever  is  suggested  to  him.  If  he  is  an  Arab, 
tell  him  that  he  is  a  sultan,  and  straightway  he  becomes  chesty,  to 
use  Devery's  term,  and  royally  orders  heads  to  be  cut  off.  TeU  him 
he  is  a  rooster,  and  he  will  crow.  I  knew  of  two  Americans  who' ex- 
perimented on  themselves,  and  when  the  first  was  told  that  he  was  Hke  a 
locomotive,  he  snorted  and  whistled,  and  kept  going  round  the  table 
puffing  and  blowing  until  he  dropped  from  sheer  fatigue.     The  other 


DRUG    HABITS  509 

somehow  conceived  the  idea  that  he  was  dead,  and  forthwith  gave 
elaborate  directions  for  his  own  funeral,  till  he  waxed  wroth  at  the 
xinseemly  mirth  of  his  companions  when  they  should  have  wept. 
Whoever  wishes  further  details  about  the  weird  play  of  this  drug  on 
the  mind  may  consult  Hugh  Ludlow's  book  on  the  hashish  smoker, 
for  he  writes  as  if  he  still  kept  up  the  habit. 

We  will  now  mention  what  may  be  truly  termed  the  "artistic 
poison."  This  is  the  mescal  button,  which  grows  on  a  low  cactus  in 
the  valley  of  the  Rio  Grande,  and,  fortimately,  is  scarce  and  hard  to  get. 
Chewing  this  button  causes  the  most  gorgeously  colored  scenes  to  ap- 
pear before  the  entranced  vision,  far  surpassing,  according  to  descrip- 
tions, the  most  magnificent  simsets.  It  would  seem  to  be  the  drug  for 
landscape  painters,  but,  unfortunately,  whatever  other  things  drugs 
do,  they  never  increase  efficiency.  It  was  first  discovered  among  the 
Kiowa  tribe  of  Indians,  who  used  it  in  their  religious  rites,  until  mission- 
aries induced  the  United  States  Government  to  remove  the  Indians 
from  where  they  could  get  it.  The  following  account,  given  by  a 
scientific  experimenter  with  it,  will  give  an  idea  of  the  extraordinary 
properties  of  this  drug: 

''When  I  chewed  the  fourth  button  there  followed  a  train  of  deHght- 
ful  visions  such  as  no  human  being  ever  enjoyed  under  normal  condi- 
tions. An  ever-changing  panorama  of  beauty  and  grandeur,  with 
infinite  variety  of  color  and  form,  hurried  before  me.  I  thought  that  I 
had  experienced  great  pleasure  on  many  former  occasions,  but  the 
experience  of  that  night  was  quite  unique  in  the  story  of  a  lifetime. 
The  colors  of  the  objects  were  wonderful,  Hke  colors  of  the  spectrum, 
intensified  as  though  in  the  fiercest  sunlight,  while  some  of  the  pictures 
were  Hke  tapestry  designs,  others  of  human  beings  in  dances,  proces- 
sions, etc.,  and  others  were  lovely  scenes  in  nature." 

We  conclude  with  one  of  the  most  damaging  of  all  these  drug  poi- 
sons, and  that  is  cocain,  which  is  derived  from  the  cola  leaf  of  a  plant 
which  grows  in  Peru  and  Bolivia.  Chewing  of  these  leaves  causes  a 
person  at  first  to  have  an  exhiliarating  feeling  of  general  muscular 
power,  rendering  him  seemingly  incapable  of  either  fatigue  or  of  hunger. 
There  is  no  doubt  that  under  its  influence  an  unusual  amount  of  fatig- 
uing exercise  may  be  taken  without  being  felt,  and  it  is  this  which 
causes  the  cocain  habit  to  be  contracted,  with  ultimately  the  most 
complete  demorahzation  of  the  individual. 

While  cocain  is  thus  consumed  in  all  parts  of  the  world,  the  British 
Government  in  India  has  been  obHged  to  prevent  its  sale  there  except 
under  the  most  stringent  regulations.     Persons  who  have  already 


5IO  CLINICAL   MEDICINE 

become  victims  to  the  opium  habit  are  peculiarly  liable  to  contract 
the  cocain  habit  also. 

But  how  about  all  this  and  ourselves?  We  seem  to  feel  and  to 
think,  and,  therefore,  to  be,  according  to  what  we  swallow.  One  can 
readily  admit  that  his  physical  frame  is  made  from  foodstuffs,  but  here 
we  note  that  if  we  take  enough  laudanum  we  think  and  feel  and  act  as 
opium  takers  do,  and  every  one  knows  how  different  a  whisky  sot  is 
from  a  teetotaler.  Our  brains,  therefore,  appear  to  be  like  those 
music-boxes  which  turn  out  different  tunes  according  to  what  disk  is 
put  into  them.  If  this  be  not  so,  then  why  can  drugs  so  specially 
modify  our  whole  mental  and  spiritual  being? 

According  to  some,  these  actual  facts  and  many  others  of  a  similar 
kind  prove  that,  after  all,  we  are  but  material  mechanisms  which  work 
solely  according  to  their  makeup.  The  logical  conclusion  from  this 
statement  is  that  man  is  altogether  a  thing,  and  a  desirable  or  an  un- 
desirable thing,  just  as  he  happens  to  be  constructed.  If  he  is  made 
badly,  as  by  birth  from  a  poor  stock,  he  will  and,  indeed,  must  be  bad, 
while  if  he  is  well  made  he  will  stay  good.  It  all  depends  on  the 
material  conditions  of  his  material  brain. 

No  sensible  person  believes  this,  and  yet  this  doctrine  seems  to  fit 
in  with  so  many  facts  that  some  clear  demonstration  of  its  fallacy  is 
much  needed.  It  is  the  physician  who  now  should  be  asked  what  he 
has  to  say  on  the  subject,  because  naturally  he  is  the  one  best  qualified 
to  know  whatever  is  known  about  both  drugs  and  brain.  Moreover, 
lately  he  has  made  great  discoveries  about  the  relations  of  the  brain  to 
the  mind  by  observations  which  he  alone  could  make ;  of  the  effects  of 
local  injuries  to  brain  matter  caused  by  disease  or  by  accident. 

But  how  different  the  facts  about  these  two  subjects  are  from  what 
most  people  imagine,  he  shows  by  saying  that  drugs  no  more  affect 
the  brain  than  insanity  itself  does — that  is,  not  at  all!  In  support  of 
this  statement  about  insanity  he  can  refer  to  the  most  complete  de- 
scription of  the  microscopic  structure  of  the  brain  lately  published, 
which  is  by  Dr.  A.  W.  Campbell  (Cambridge  University  Press,  1906), 
and  is  based  on  laborious  investigations  of  8  normal  human  brain 
hemispheres  compared  with  the  brains  of  2  chimpanzees  and  i  orang. 
But  of  the  8  human  hemispheres,  6  were  those  of  lunatics  who  died  in- 
sane. Dr.  Campbell  merely  remarking  of  them  "that  he  was  convinced 
from  a  lengthy  experience  in  the  pathologic  laboratory  attached  to  the 
Rainhill  Asylum  that  in  such  lunatics  all  the  microscopic  methods  at 
our  disposal  will  fail  to  disclose  changes,  either  in  the  nerve-cells  or 
fibers,  which  we  can  refer  to  their  altered  mental  condition."     In  other 


DRUG   HABITS  51I 

words,  that  insanity  neither  affects  nor  deranges  the  brain  struc- 
turally. 

As  to  the  drugs  which  we  have  mentioned,  he  denies  that  any  of 
them  injure  the  brain  except  alcohol,  which  does  injure  the  brain, 
though  not  at  all  on  account  of  its  mental  effects,  but  for  the  very 
different  reason  that  alcohol  has  a  chemical  affinity  for  the  albumin 
and  fats  of  the  tissues.  By  this  chemical  action  it  slowly  alters  and 
damages  brain  tissues,  but  this  result  in  nowise  differs  from  similar 
alterations  produced  by  alcohol  in  the  tissues  of  the  liver  and  of  the 
kidneys.  Tissue  changes  in  the  brain  will,  of  course,  derange  its  work- 
ing, as  is  illustrated  also  by  the  destruction  of  the  mind  accompanying 
that  ruin  of  brain  matter  caused  by  the  slow  action  of  the  virus  of 
syphilis  when  it  causes  paresis,  or  the  so-called  general  paralysis  of  the 
insane.  Those  drugs  whose  mental  effects  we  have  described  never  leave 
a  trace  of  their  action  on  the  brain,  nor  do  any  other  similar  agents. 

Further,  he  has  discovered  that  in  what  may  be  called  the  human 
half,  in  distinction  from  the  animal  hemisphere,  are  the  actual  material 
places  where,  and  only  where,  the  great  and  exclusively  human  mental 
faculties  reside.  Elsewhere  in  the  head  they  are  not  found.  The  anat- 
omist had  noted  before  that  our  brain  matter  is  collected  in  two  sym- 
metric hemispheres,  which  are  as  perfect  pairs  as  our  two  eyes  and  our 
two  ears,  while  the  physiologist  is  certain  that  originally  both  hemi- 
spheres are  equally  good  for  acquiring  mental  endowments.  But 
neither  anatomist  nor  physiologist  can  see  the  brain  thinking.  None 
but  the  physician,  by  his  above-mentioned  observations,  would  have 
discovered  that  even  a  special  mental  operation  must  have  its  own  little 
special  locality  among  the  many  other  mind-endowed  places  in  the 
human  hemisphere. 

Thus,  Ralph  Waldo  Emerson  Hved  for  some  time  no  longer  Emer- 
son in  word  or  thought.  He  began  by  losing  not  only  his  verbs,  but  all 
his  nouns,  because  the  place  for  nouns  in  his  left  brain  was  spoiled.  He 
had  the  same  place  all  right  in  his  other  hemisphere,  but  it  was  then  too 
stiff  with  age  to  take  the  impress  of  a  single  noun.  But,  Hkewise,  all 
the  chief  mental  faculties  may  go  together  if  the  damage  is  extensive 
enough  in  the  thinking  half.  One  of  the  strongest  thinkers  and  best 
trained  writers  in  my  acquaintance  was  suddenly  so  totally  wrecked 
mentally  that  he  was  not  only  speechless,  but  could  not  recognize  any 
one  of  his  family,  and  he  remained  so  for  months,  though  until  his  death 
his  right  hemisphere  was  as  sound  as  ever. 

In  my  book  "  Brain  and  Personality  "  I  have  explained  why  it  is 
that  the  left  hemisphere  in  right-handed  persons  and  the  right  hemi- 


512 


CLINICAL  MEDICINE 


sphere  in  the  left-handed  is  the  human  brain.  Briefly,  the  two 
brain  hemispheres  in  our  head  are  analogous  to  two  phonographs,  be- 
cause phonographs  can  no  more  themselves  cover  their  wax  leaves  with 
words  expressing  ideas  than  they  can  make  wax  think.  The  phono- 
graphs are  wonderful  instruments,  but  they  are  never  anything  but 
instruments;  and  so  the  brain  hemispheres  are  the  instruments  of  the 
thinker,  and  nothing  more,  for  if  they  could  themselves  think,  then 
both  hemispheres  would  think  as  a  matter  of  course,  when,  as  a  matter 
of  fact,  only  one  of  them  has  a  single  imprint  of  the  human  mind  in  it. 

What  is  it,  therefore,  that  thinks?  Unquestionably,  it  is  the  human 
personality,  which  is  itself  independent  of  the  brain  that  it  uses.  So 
far  as  the  brain  is  concerned,  it  is  simply  physical  in  its  structure  and 
chemical  in  its  composition.  But  here,  in  one  of  its  halves,  we  are  face 
to  face  with  the  tremendous  exception  to  everything  earthly.  The  evo- 
lutionist can  make  a  good  showing  that  in  structure  man's  brain  differs 
but  little  from  the  chimpanzee's,  just  as  it  should  in  the  ascending 
series  of  animals,  but  when  it  comes  to  the  human  mind  the  evolutionist 
has  to  quit.  What  but  a  mind  worked  by  a  man  could  both  weigh  and 
accurately  locate  in  the  heavens  a  great  planet  which  neither  he  nor 
any  one  else  has  yet  seen?  And  so  the  human  world  abounds  with  in- 
numerable utter  impossibilities  for  mere  animals  to  achieve. 

Mentally,  therefore,  man  is  as  much  out  of  keeping  with  the  entire 
succession  and  developments  of  evolution  as  any  being  from  another 
world  would  be,  and  those  who  still  would  say  that  because  the  human 
brain  so  closely  resembles  that  of  the  ape  those  two  cannot  be  far  apart, 
are  themselves  their  only  good  arguments.  Meanwhile,  for  this  human 
thinker  one  instrument  for  thinking  is  enough,  and  he  does  not  need 
two  hemispheres  any  more  than  a  violinist  needs  two  violins.  The  sec- 
ond hemisphere  is  then  only  to  provide  against  accidental  damage  to 
the  first,  when,  if  he  be  yet  young,  the  thinker  can  in  time  teach  it  to 
become  human  also  in  mental  powers,  but  not  if  its  cords  have  become 
too  stiffened  with  age. 

The  bearing  of  these  facts  on  the  subject  of  the  action  of  drugs  on 
the  mind  is  this,  that  if  the  brain  is  as  much  the  instrument  of  the 
thinker  as  his  hand  is  the  mechanic's,  then  the  work  which  it  can  do  will 
depend  on  the  physical  conditions  of  the  instrument  itself.  A  watch- 
maker may  be  as  skilful  as  ever  at  his  trade,  but  he  can  hardly  mend 
a  watch  with  gloves  on,  still  less  if  he  puts  his  hands  in  mittens.  But 
that  is  just  what  the  thinker  does  with  his  instrument  for  thinking 
when  he  gets  drunk.  Alcohol  in  one  amount  will  hamper  the  working 
of  his  brain  instrument  as  much  as  gloves  would  the  fingers  of  the  watch- 


DRUG    HABITS  513 

maker,  and  in  increased  quantity  will  make  it  wholly  unworkable. 
Instruments  are  never  more  than  instruments,  however  they  work. 
The  eye  is  the  instrument  for  seeing,  and  man  has  invented  an  opera- 
glass  to  make  it  see  better.  If  one  of  this  instrument's  lenses  is  made 
of  blue  or  green  or  yellow  glass,  everything  seen  through  it  will  appear 
blue  or  green  or  yellow  accordingly;  but  is  it  the  opera-glass  or  the 
person  using  it  that  sees? 

But  if  we  are  not  our  brains,  nor  our  brains  the  same  with  us,  then 
what  are  we?  The  wise  injunction  of  the  old  Greek  sage,  "know  thy- 
self," is  as  binding  now  as  ever,  for  the  self  in  us  is  the  hardest  of  all 
things  to  know,  and,  therefore,  what  facts  modern  medical  science  is 
able  to  add  to  that  knowledge  should  not  be  neglected.  Our  subject 
of  mind  and  drugs  is  now  seen  to  be  a  test  almost  like  a  laboratory  test 
of  what  the  self  in  us  is,  with  the  result,  imexpected  to  many,  that  as 
we  are  not  our  brains,  neither  are  our  minds  wholly  the  same  with  our- 
selves. The  real  self  in  us  is  as  far  superior  to  the  mind  as  mind  is 
superior  to  the  brain.  We  shall  see  that  the  mind  has  httle  reason  to 
dread  the  drug,  but  the  self  indeed  has,  and  should  regard  the  drug  as 
a  most  dangerous  enemy. 

When  we  consider  what  the  faculties  of  the  mind  are,  such  as  mem- 
ory, imagination,  perception,  and,  above  all,  understanding  or  reason, 
it  would  seem  that  we  could  not  ask  for  anything  more  to  complete  our 
individuality.  But  the  truth  is,  that  a  man's  mind  is  not  himself,  but 
his,  and  because  it  is  his  it  is  perfectly  detachable  from  his  true  self, 
so  that  he  can  hire  it  out,  as  he  would  a  wagon  which  he  owns.  This 
is  just  what  lawyers  do  for  their  living.  To  his  client  the  lawyer  hires 
out  his  whole  mental  equipment  of  learning,  power  of  expression,  of 
persuasion,  and  of  reasoning,  and,  if  desirable,  he  will  throw  his  emo- 
tions into  the  bargain.  A  noted  criminal  lawyer  in  New  York  had  a 
valuable  asset  in  his  tears,  which  he  had  so  well  on  tap  that  when  he 
saw  that  the  psychologic  moment  had  arrived  scarce  a  jury  could 
stand  the  gush.  But  was  he  himself  in  evidence  then,  or  only  his 
lacrimal  apparatus?  Without  his  fee  there  would  not  have  been  a  tear. 
But  lawyers  are  no  different  from  other  people  in  this  respect.  Every- 
one's mind  is  entirely  distinct  and  separable  from  himself. 

The  highest  element  in  us  is  the  will.  We  are  thus  brought  finally 
to  that  centric  element  in  us  which,  as  we  have  said,  outranks  the  mind 
as  truly  as  the  mind  outranks  the  body.  We  are  altogether  what  it  is, 
whether  we  be  strong  or  weak,  good  or  bad,  for  as  it  slowly  molds  brain, 
so  it  slowly  but  permanently  molds  that  most  personal  of  things— char- 
acter. It  is  the  conscious  purpose  alone  in  us  which  does  anything,  and 
33 


514  CLINICAL   MEDICINE 

what  can  a  strong  purpose  not  do,  especially  with  brain  matter?  How 
this  fact  alters  all  standards  of  estimation !  Excellence  of  body  is  good, 
but  that  does  not  lessen  the  number  of  handsome  fools  or  of  silly  beau- 
ties. Fine  mental  gifts  are  great  gifts,  but  that  does  not  prevent  many 
of  their  possessors  from  being  failures  in  life's  upward  way,  because 
they  had  no  staying  power  for  the  climb.  A  man  with  a  strong  will 
can  make  his  human  hemisphere  abound  with  great  educated  centers, 
because  he  can  take  the  time  and  the  trouble  to  make  them.  The 
bright  but  weak-willed  man  does  little  after  he  is  fifty  but  sigh  over 
past  indolence  or,  more  commonly,  whine  at  his  bad  luck. 

But  we  must  now  come  back  to  our  original  subject — drugs — though 
in  such  a  connection  as  to  make  the  mere  mention  of  them  repulsive. 
On  the  one  side  is  a  splendid  being,  with  a  majestic  endowment,  where- 
by he  can  rule  and  direct  both  body  and  mind,  and  himself  make  a 
brain  matchless  for  its  powers.  On  the  other  is  a  human  wreck,  wholly 
thus  from  addiction  to  a  drug.  Did  that  baleful  agent  injure  his  body? 
Not  much,  for  I  have  known  a  victim  of  opium  to  outlive  both  near 
relatives  and  friends  of  former  years.  Nor  do  such  things  perceptibly 
injure  the  mind,  for  many  of  these  poor  creatures  can  yet  talk  beauti- 
fully and  write  elegantly.  But  in  them  the  will  can  no  longer  rule! 
That  is  why  the  man  is  ruined.  The  drug  has  completely  dethroned 
the  will,  and  when  the  will  falls  everything  good  in  the  man  comes  down 
with  it.  In  short,  the  whole  ruinous  power  of  such  drug  habits  is  that 
they  dethrone  the  will  from  its  rightful  sway  over  everything  in  us. 
How  it  does  this  is  an  impenetrable  mystery.  Practically  the  only  sure 
way  for  the  victim  to  recover  from  the  evil  sway  of  his  drug  is  to  get 
away  from  it;  by  his  bodily  removal  from  where  he  can  get  it.  This 
measure  may  be  difficult  to  attain,  but  still  remains  the  only  certain 
cure. 


CHAPTER    XV 

MINERAL   POISONS 

Wholly  different  from  the  drug  poisons  which  we  have  just  been 
discussing  are  those  common  poisons  which  are  of  a  metallic  nature, 
namely,  arsenic  and  lead.  When  we  are  sure,  owing  to  their  character- 
istic symptoms,  of  their  presence  in  the  body,  it  may  not  be  easy  in  some 
cases  to  discover  how  they  entered  it.  Thus,  I  was  called  in  consulta- 
tion by  a  physician  to  see  a  woman  dying  from  symptoms  of  profound 
anemia  without  emaciation  or  fever.  She  told  me  that  her  husband 
had  died  with  just  the  same  symptoms  a  year  before.  On  examination 
I  soon  became  convinced  that  nothing  but  chronic  arsenic-poisoning 
would  account  for  her  condition.  I  first  asked  if  she  had  been  sleeping 
in  a  room  with  green-colored  wall  paper,  because  certain  arsenic  dyes, 
which  never  fade,  were  once  used  by  manufacturers  of  wall  papers  until 
they  were  forbidden  to  do  so  by  law.  Similarly,  no  articles  of  furniture 
with  green  baize  covering  were  to  be  found,  but  I  found  that  she  and 
her  husband  owned  the  fine  house  in  which  they  Hved,  and  whose  apart- 
ments they  rented,  leaving  for  themselves  only  the  basement,  in  which 
they  dwelt  and  slept.  From  the  large  front  room  of  this  basement 
they  derived  a  further  revenue,  which  itself  was  the  cause  of  their 
deaths,  by  letting  it  out  for  the  reception  of  deer  and  musk-oxen  and 
elks  head?  consigned  to  their  keeping  by  their  owners  in  the  summer 
months.  Now  these  animal  heads  can  be  preserved  from  attacks  by 
insects  or  by  molds  by  being  charged  with  arsenic,  and  these  persons 
were  accustomed  frequently  to  go  into  this  room  to  brush  the  dust  off 
these  objects.  I  accordingly  directed  that  the  woman's  urine  should  be 
examined  for  the  presence  of  arsenic,  and  this  was  found  in  abundance 

at  the  laboratory. 

LEAD-POISONING 

The  origin  of  poisoning  by  lead  may  often  be  just  as  difficult  to 
demonstrate.  I  had  a  gentleman  who  had  been  a  patient  of  mine  for 
years,  who  came  to  me  for  a  localized  pain  just  above  the  pubis.  He 
had  been  sounded  several  times  by  eminent  surgeons  for  stone  in  his 
bladder  without  finding  any.  At  last,  when  he  said  the  pain  was  intol- 
erable, I  concluded  to  try  the  faradic  current  through  the  rectus  muscle, 

515 


5l6  CLINICAL   MEDICINE 

to  see  if  that  would  relieve  his  pain;  on  doing  so  I  discovered  that  this 
muscle  would  not  respond  to  the  electric  current;  this  at  once  sug- 
gesting to  me  that  it  all  was  due  to  lead-poisoning.  As  no  other  mem- 
bers of  his  family  had  such  symptoms,  I  asked  if  he  was  accustomed  to 
drink  the  water  from  the  faucet  early  in  the  morning  before  any  one 
else,  and  failing  that,  whether  he  frequented  soda  water  fountains  at 
such  times;  as  he  denied  both  these  questions,  I  then  asked  him  whether 
he  used  any  hair  dye  on  his  thinly  covered  scalp;  he  admitted  that  he 
had  for  fourteen  years.  On  asking  for  a  specimen  of  this  hair  dye,  I 
found  it  to  be  a  pure  sulphite  of  lead,  which  sufficiently  accounted  for 
his  trouble.  Not  long  afterward  he  walked  the  street,  a  white-haired 
man,  but  with  no  pain  over  his  pubis. 

Symptoms. — We  begin  with  the  symptoms  of  lead-poisoning;  which 
are  so  common  that  it  is  doubtful  whether,  in  the  conditions  of  our 
modern  life,  many  persons  escape  having  some  lead  deposited  in  their 
tissues,  but  when  minute  in  quantity  this  will  occasion  no  perceptible 
derangements.  In  my  experience  the  commonest  symptoms  to  excite 
suspicion  are  recurrent  neuralgic  pains  throughout  the  limbs,  and  espe- 
cially in  the  arms.  I  have  often  noticed  these  to  occur  in  farmers' 
wives,  in  whom  I  had  my  suspicions  first  aroused  by  finding  that  they 
had  a  high-tension  pulse,  with  sometimes  tophi  in  their  external  ears, 
thus  showing  their  tendency  to  gouty  disorders.  Now  lead-poisoning 
has  long  been  known  for  its  HkeHhood  to  engender  gout,  and,  on  further 
inquiry,  I  found  these  women  drank  water  supplied  through  lead  pipes 
brought  from  a  distant  spring. 

The  more  pronounced  sjnnptoms  of  lead-poisoning,  however,  occur 
in  those  whose  occupation  causes  them  to  be  in  constant  contact  with 
lead.  Thus,  it  may  occur  in  printers,  who,  while  setting  up  type,  often 
hold  the  type  in  their  mouths.  It  is,  however,  painters  who  suffer  the 
most.  As  we  have  remarked  before,  the  skin  does  not  absorb  water 
unless  in  the  form  of  watery  vapor  or  steam,  but  painters  using 
white  lead  are  much  more  quickly  poisoned  when  they  add  turpentine, 
which  is  volatile,  in  mixing  their  paints.  On  that  account  I  have  found 
coach  and  carriage  painters,  who  use  various  varnishes  in  their  work, 
therefore  particularly  susceptible.  Those  engaged  in  the  smelting 
of  lead  ores  are  often  attacked,  owing  to  the  lead  being  vaporized 
by  heat.  Wines  and  cider  which  contain  acids  quickly  become  con- 
taminated in  contact  with  lead.  The  susceptibility  to  lead-poisoning  is 
also  greater  in  women  than  in  men,  some  putting  it  as  high  as  4  to  i. 

It  is  probable  that  the  commonest  mode  of  entrance  is  by  the  ali- 
mentary canal,  but  other  avenues  are  also  opened,  particularly  the 


LEAD-POISONING  517 

lungs,  which  inhale  as  a  vapor,  and  the  skin,  by  direct  contact. 
Lead  has  a  particular  affinity  for  certain  muscles.  Thus  it  affects  the 
extensors  of  the  forearm  and  wrist,  and  also  the  rectus  abdominis 
muscle;  such  muscles  are  found  to  be  degenerated  and  look  yellow, 
fatty,  and  fibroid,  while  the  nerves  show  a  special  degenerative  neuritis. 

The  symptoms  of  lead-poisoning  may  be  either  acute  or  chronic. 
Thus,  there  may  be  a  rapidly  developing  anemia  accompanied  by 
severe  nervous  symptoms,  such  as  convulsions  and  delirium  not  unlike 
those  of  acute  alcohoHsm.  Some  cases  which  are  soon  fatal  are  accom- 
panied by  severe  gastro-intestinal  symptoms. 

Changes  in  the  blood  are  common,  but  not  hmited  to  lead-poison- 
ing, except  that  such  changes  are  so  much  more  pronoimced  after 
lead  that  they  may  be  of  diagnostic  importance.  These  changes  con- 
sist in  a  granular  basophihc  degeneration.  One  of  the  most  significant 
findings  is  the  presence  of  nucleated  red  corpuscles. 

By  far  the  most  distinctive  sign  is  the  blue  line  at  the  junction  of 
the  gums  with  the  teeth,  due  to  the  precipitation  of  sulphite  of  lead, 
caused  by  combination  with  the  tartar  of  the  teeth.  This  should  always 
be  looked  for,  as  it  may  be  removed  by  the  daily  use  of  the  tooth- 
brush. This  .does  not  occur  commonly  in  mechanics  exposed  to  lead, 
and,  therefore,  is  one  of  the  most  frequent  signs  to  be  found  in  lead 
workers. 

The  most  common  symptom,  however,  is  the  well-known  lead-coHc, 
which  is  found  preceded  by  obstinate  constipation;  the  pain  may  be 
diffused,  but  is  most  pronoimced  about  the  umbilicus,  when  it  may  be 
suspected  by  the  gesture  of  the  patient  describing  it.  He  forcibly 
grasps  the  part  and  moves  his  hand  as  if  it  were  like  the  pain  of  an  augur 
being  driven  into  that  part;  this  at  once  shows  that  it  is  not  an  inflam- 
matory pain;  moreover,  it  does  not  extend  to  the  back,  as  in  the  hepatic 
colic,  nor  down  the  groins,  as  in  renal  colic.  In  other  words,  lead-coHc 
has  all  the  characteristics  of  a  true  colic,  coming  on  Hke  other  such  affec- 
tions in  paroxysms,  which  may  be  succeeded  by  a  general  soreness  in  the 
parts. 

Lead-palsy  is  so  peculiar  in  its  symptoms  that  it  may  be  itself  di- 
agnostic, appearing  almost  exclusively  in  the  forearm  and  affecting  the 
extensors,  so  as  to  cause  that  characteristic  wrist-drop  sometimes  seen 
only  in  the  arm  which  is  most  used,  namely,  the  right,  but  usually  in 
both,  besides  paralysis  of  the  extensors  of  the  wrist.  The  extensors  of 
the  fingers  may  also  be  affected. 

Rarely  we  have  the  brachial  type,  which  involves  the  deltoid,  and 
the  brachial  anticus,  so  that  the  arm  cannot  be  raised. 


5l8  CLINICAL  MEDICINE 

A  very  frequent  form  of  which  workmen  bitterly  complain  is  when 
the  interossei  muscles  are  attacked  and  wasted,  so  that  the  hand  is 
incapacitated  for  performing  any  fine  work. 

While  the  upper  limbs  are  attacked  in  about  85  per  cent,  of  all  cases, 
the  lower  limbs  may  be  affected  in  from  12  to  15  per  cent.,  though  in 
my  experience  the  percentage  is  much  less,  but  doubtless  is  higher 
among  those  observers  who  have  more  extensive  opportunities  among 
workmen  in  factories.  When  the  lower  limbs  are  attacked  it  is  usually 
the  peroneal  muscles;  the  extensors  of  the  toes,  including  the  big  toe,  are 
affected,  producing  the  "steppage"  gait. 

In  the  larynx  adductor  paralysis  has  been  noted  by  certain  laryn- 
gologists. 

Rare  instances  are  referred  to  in  medical  literature  of  a  general 
paralysis  of  all  muscles  below  the  neck,  accompanied  with  wasting,  and 
due  to  lead-poisoning,  this  diagnosis  being  further  confirmed  by  recov- 
ery after  special  treatment. 

Lead-poisoning  may  be  fatal  in  those  acute  cases  in  which  the  brain 
itself  is  affected.  These  patients  may  have  true  epileptic  convulsions, 
followed  in  some  cases  by  delirium,  and  in  others  by  coma,  following 
either  convulsions  or  delirium. 

Treatment. — In  all  cases  of  lead-poisoning  of  whatever  form  or  de- 
gree the  first  indication  is  to  get  rid  of  the  lead.  We  can  depend  upon 
the  kidneys  for  doing  that  quite  promptly  if  we  administer  iodid  of 
potassium  in  5-  to  lo-gr.  doses,  which  combines  with  the  lead  wherever 
it  is  found,  as  iodid  of  lead  is  quickly  eliminated  in  the  urine.  In 
obscure  cases  this  may  be  used  for  diagnosis  by  the  appearance  of  iodid 
of  lead  in  the  urine. 

The  treatment,  however,  of  the  wasted  muscles  takes  much  more 
time,  but  for  this  we  fortunately  possess  a  very  effective  agent  in  the  far- 
adic  current  of  electricity.  This  is  particularly  illustrative  in  the  restor- 
ation of  the  small  wasted  interossei,  to  which  we  have  already  referred, 
because  this  current  is  always  limited  in  direction  to  the  shortest  dis- 
tance between  its  two  poles.  Two  electrodes  tipped  with  sponges  may 
then  be  applied,  one  at  each  end  of  the  affected  muscle,  and  the  current 
continued  for  fifteen  minutes.  This  done  four  times  a  day,  the  muscle, 
in  about  a  week,  will  be  found  to  have  recovered  its  bulk  and  equally  so 
its  function.  In  longer  muscles,  as  in  those  of  the  shoulder  and  upper 
arm,  or  in  the  case  of  the  rectus  abdominis,  the  same  good  results  of 
this  current  are  obtained. 

An  occasional  morning  purge  of  magnesium  sulphate  may  be  pre- 
scribed. 


ARSENIC-POISONING  519 

ARSENIC-POISONING 

Acute  poisoning  by  arsenic  rarely  occurs  except  when  it  is  taken  with 
suicidal  intent,  and  we  would  refer  the  reader  to  treatises  on  toxicology 
for  both  the  symptoms  and  treatment  of  such  patients.  We  have 
already  referred  in  this  chapter  to  chronic  arsenic-poisoning,  the 
sources  of  which  may  be  very  numerous,  as  mentioned  in  the  case  there 
detailed.  It  is  otherwise  when  arsenic  has  been  administered  as  a 
medicine,  as  in  the  treatment  of  chorea,  which  I  have  condemned. 
Arsenic  is  also  often  employed  as  a  remedy  in  chronic  disorders  of  the 
blood,  as  in  pernicious  anemia,  but  its  most  common  and  prolonged  use 
is  in  the  treatment  of  psoriasis,  where  it  is  often  quite  beneficial. 
Psoriasis,  however,  is  best  managed  by  omitting  everything  like  the 
red  meats  in  the  dietary,  but,  however  used,  the  physician  should  be  on 
the  watch  for  the  first  symptoms  of  arsenic-poisoning.  These  are  a 
sense  of  weight  or  uneasiness,  with  tenderness  on  pressure  at  the  epi- 
gastrium. Conjoined  with  this  is  a  puffiness  of  the  eyelids,  and  after 
a  time  numbness  and  tingling  in  the  fingers,  and  sometimes  with  the 
same  symptoms  in  the  toes.  When  these  symptoms  first  develop  the 
arsenic  should  be  abandoned,  or  only  resumed  after  the  system  has  had 
time  to  get  rid  of  it.  Arsenic-poisoning  has  also  occurred  in  women  who 
have  taken  the  drug  for  the  improvement  of  their  looks,  on  the  mis- 
taken supposition  that  it  causes  a  better  complexion. 

We  have  some  curious  illustrations  of  the  tolerance  by  the  stomach 
or  general  system  of  such  corrosive  poisons  as  arsenic  in  corrosive  sub- 
limate which  are  difificult  to  explain.  Thus,  the  peasants  in  the  district 
of  Styria,  Austria,  may  take  as  much  as  8  gr.  of  arsenous  acid  a  day, 
and  a  Turkish  soldier  once  in  my  presence  took  from  8  to  10  gr.  of 
corrosive  sublimate,  which  he  licked  off  the  pahn  of  his  hand,  to  the 
great  alarm  of  the  native  Christian  apothecary  who  sold  it  to  him. 
I  personally  watched  this  soldier  for  an  hour  after  he  had  taken  such 
a  quantity  of  this  poison,  but  he  only  laughed  at  me,  and  said  that  he 
took  this  drug,  like  other  people  in  his  country,  for  improving  his  sexual 
power. 

Prolonged  administration  of  arsenic,  however,  may  produce  a  char- 
acteristic pigmentation  of  the  skin  and  occasionally  ulceration  of  the 
cornea. 


CHAPTER   XVI 

DISEASES  OF  THE  NERVOUS  SYSTEM 

GENERAL  INTRODUCTION 

Authors  have  very  properly  divided  nervous  diseases  into  func- 
tional and  organic.  This  cannot  be  done  in  the  case  of  any  other  tissue 
or  organ  of  the  body.  Thus,  no  disorders  of  the  lungs,  liver,  or  kid- 
neys are  called  functional,  because  their  causes  are  generally  to  be 
found  in  structural  changes  in  them,  but  the  most  diligent  search  in 
nervous  structures  may  altogether  fail  to  discover  the  organic  change  to 
which  melanchoHa  or  epilepsy  are  due.  The  important  conclusion 
from  this  fact  is,  that  we  should  look  elsewhere  than  in  nervous  struc- 
tures for  the  true  origin  of  what  are  well- termed  functional  nervous 
disorders. 

Organic  nervous  derangements  may  be  divided  into  the  accidental 
and  the  primary  classes.  In  the  accidental  class  the  cause  is  not  in  the 
nervous  mechanism.  Thus,  the  entrance  of  a  bullet  into  the  cranium 
may  cause  all  the  s3nTLptoms  of  an  ordinary  hemiplegia.  But  no  one 
would  think  of  blaming  the  brain  for  this  damage.  Yet  an  apoplectic 
clot  is  usually  just  as  much  the  physical  origin  of  a  hemiplegia  as  any 
other  physical  agent.  But  in  this  case  it  may  be  a  purely  arterial  and 
not  a  cerebral  disorder  which  causes  the  accident  to  the  brain. 

Primary  organic  nervous  diseases,  on  the  other  hand,  are  recogniz- 
able by  demonstrable  and  characteristic  changes  in  nervous  tissues 
themselves.  Thus,  in  tabes  the  posterior  columns  of  the  spinal  cord 
are  found  shrunken  and  wasted,  because  their  constituent  neurons 
are  so  evidently  by  the  action  of  a  specific  toxin.  How  far  other  or- 
ganic nervous  degenerations  are  similarly  caused  by  toxins  is  not  yet 
known,  and  is  an  important  subject  of  research. 

The  term  "neuron"  should  here  be  defined.  We  no  longer  think 
of  the  nervous  system  being  composed  of  a  collection  of  specific  cells, 
Hke  the  specific  cells  which  make  up  the  substance  of  Hver  or  kidney, 
but  of  a  collection  of  an  immense  number  of  imits,  composed  of  a  cell 
with  its  dynamic  center  in  the  nucleus  and  the  cell  body,  which  is  itself 
traversed  by  innumerable  nerve-fibrils,  many  of  which  come  to  it 
from  without,  and  are  called  dendrites,  while  others  are  collected  into 

520 


GENERAL    INTRODUCTION  52 1 

what  is  called  the  axon,  which  leads  away  from  the  cell  body.  The 
axon  may  be  very  long,  reaching  from  a  cell  in  the  brain  cortex  to  the 
termination  of  the  pyramidal  tract  in  the  spinal  cord.  In  its  course 
the  axon  gives  off  a  succession  of  its  fibers  at  right  angles,  and  finally 
ends  in  a  brush-Hke  termination  in  a  muscle  or  gland.  But  the  point  is, 
that  the  fibrils  of  a  neuron  do  not  actually  anastomose  with  the  fibrils 
of  other  neurons,  because  simple  contact  with  them  is  enough  for  the 
functions.  In  this  sense,  a  neuron  is  an  independent  entity.  Neu- 
rons, when  they  have  the  same  functions,  are  usually  collected  into 
bundles.  These  bundles  are  often  contained  in  sheaths,  and  thus 
acquire  the  name  of  nerves,  as  the  facial,  uhiar,  or  other  nerves. 

The  independence  of  neurons  is  often  illustrated  both  in  health 
and  in  disease.  Thus,  the  brain  cannot  of  itself  get  a  single  muscle  to 
act.  It  must  ask  the  neurons  of  the  spinal  cord  to  do  that,  for  without 
the  spinal  cord  no  voluntary  muscle  will  do  anything,  not  even  a  Little 
wink.  In  diseases,  as  in  tetanus,  the  spinal  cord  may  tear  the  body 
by  violent  muscular  contractions  till  death  foUows,  the  brain  meanwhile 
being  helpless  to  prevent  it,  so  whole  classes  of  nervous  diseases  are 
due  to  the  morbid  independence  of  the  spinal  neurons. 

We  now  should  mention  the  important  place  which  is  held  in  aU. 
nervous  functions  by  what  is  technically  called  inhibition.  To  inhibit 
means  to  check,  and  from  the  simplest  response  of  a  spinal  nerve-center 
to  a  stimulus,  up  to  the  most  complex  mental  process  in  the  brain  cor- 
tex, we  meet  with  what  are  virtually  mutual  checking  operations. 
Thus,  when  flexor  muscles  are  made  to  contract,  the  corresponding 
extensor  muscles  should  simultaneously  relax,  not  passively,  but  ac- 
tively, for  it  is  now  known  that  muscular  relaxation  needs  its  proper 
stimulus  to  relax,  as  otherwise  the  muscle  wiU  spontaneously  pass  into 
the  contraction  of  rigor  mortis. 

One  of  the  most  striking  examples  of  inhibition  is  found  in  the  nor- 
mal actions  of  the  heart.  This  organ  is  supplied  by  a  set  of  nerves 
coming  from  the  spinal  cord,  called  the  accelerators,  because  their 
stimulation  causes  the  heart  to  beat  faster.  But  it  is  also  suppHed 
with  inhibitory  fibers  coming  through  the  vagus,  which  make  the  heart 
beat  slower.  Cut  these  inhibiting  nerves,  and  the  heart  bounds  off 
Hke  a  rimaway  horse  which  has  thrown  its  rider.  So  powerful  is  the 
action  of  the  inhibitory  vagus  nerves  that  they  may  cause  death  by 
bringing  the  heart  to  a  permanent  stop,  as  in  some  cases  of  mental 
shock. 

But  inhibition  meets  us  at  every  turn  in  studying  the  operations  of 
the  nervous  system.     In  the  spinal  cord  we  find  a  succession  of  ner- 


52  2  CLINICAL   MEDICINE 

vous  centers,  one  above  the  other,  each  lower  set  being  regulated  by 
inhibition  of  the  centers  above  it,  until  we  reach  the  brain,  which  by 
rights  should  regulate  the  whole.  In  short,  a  normal  human  nervous 
system  is  Hke  a  great  well-disciplined  army,  with  every  kind  of  rank  in 
its  officers,  from  the  lowest  to  the  highest;  and  many  serious  nervous 
diseases  are  due  to  the  loss  of  inhibitory  discipline. 

Embryologically,  the  spinal  cord  is  the  original  nervous  system, 
the  gangha  of  the  special  senses  being  afterward  developed  upon  it, 
the  nuclei  of  which  remain  in  the  medulla.  As  we  have  before  re- 
marked, the  movements  of  every  muscle  of  the  body  are  primarily 
caused  by  impulses  proceeding  from  the  spinal  centers.  With  the 
further  development  of  the  brain  itself  the  neurons  of  the  nervous  sys- 
tem are  divided  into  two  great  segments,  the  upper  one  on  the  motor 
side  consisting  of  the  fibers  that  compose  the  pyramidal  tract,  which, 
beginning  at  the  cortex  of  the  brain,  then  converge  to  a  compact  bundle, 
passing  through  the  internal  capsule,  then  through  the  pons  and  crura 
cerebri,  and  so  on  to  the  floor  of  the  fourth  ventricle  in  the  medulla, 
where  they  form  a  pyramidal  bundle,  from  which  the  whole  tract  gets 
its  name.  At  the  lower  end  of  the  medulla  the  fibers  of  the  pyramidal 
tract  decussate,  so  that  the  motor  impulses  of  the  left  hemisphere 
correspondingly  govern  the  right  side  of  the  body.  The  pyramidal 
tract  from  this  on  is  constantly  giving  off  its  fibers,  until  it  ends  about 
the  middorsal  region  of  the  spinal  cord.  Meantime  these  neurons 
from  the  corticopyramidal  tract  do  not  connect  directly  with  the 
cells  or  processes  of  the  spinal  motor  centers,  but  end  in  a  network  of 
fibers  around  the  spinal  motor  cells,  in  the  anterior  horn  of  the  gray 
matter  of  the  spinal  cord.  In  this  way  the  upper  segment  of  the 
motor  tracts  coming  from  the  cortex  are  constituted.  The  lower 
segment  begins  with  the  cells  in  the  anterior  horn  of  the  spinal  gray 
matter,  whose  fibers  continue  on  till  they  end  in  what  are  called  muscle 
plates  in  the  voluntary  muscles,  while  others  end  in  the  cells  of  a 
secretory  gland. 

Thus,  every  voluntary  muscle  of  the  body  is  directly  governed  by 
the  neurons  of  the  lower  segment.  The  brain,  therefore,  cannot 
directly  act  upon  any  muscle,  as  we  have  remarked,  but  only  through 
the  mediation  of  the  motor  cells  of  the  spinal  cord. 

All  motor  operations  of  the  spinal  cord  proceed  from  within  out- 
ward, and  hence  are  called  efferent.  All  sensory  operations,  on  the 
other  hand,  proceed  from  the  outside  inward,  and  hence  are  called 
afferent.  But,  whereas  the  efferent  or  motor  impulses  are  relatively 
simple,  the  afferent  stimuH  come  from  the  whole  outer  world,  and, 


EPILEPSY  523 

therefore,  are  so  varied  that  their  tracts  inward  and  upward  in  the 
spinal  cord  become  very  complex,  corresponding  to  transmissions  of 
the  muscle  sense,  of  the  sense  of  touch,  of  heat  and  cold,  and  of  pain, 
with  their  several  varieties. 

Besides,  there  is  an  anatomic  difference,  consisting  of  a  spinal  gan- 
glion found  on  each  sensory  root  before  it  enters  the  cord.  This 
ganglion  on  the  posterior  root  of  each  sensory  spinal  nerve  is  composed 
of  peculiar,  bipolar  cells,  whose  processes,  at  first  single,  soon  divide 
like  the  letter  "T."  One  branch  enters  the  spinal  cord  via  the  pos- 
terior root,  the  other  to  constitute  a  sensory  nerve-fiber  to  be  distrib- 
uted to  some  sensory  surface.  The  striking  characteristics  of  this  cell 
are  that  it  gives  rise  to  two  nerve-fibers,  and  that  it  possesses  no  den- 
dritic processes.  Exactly  similar  cells  are  found  in  the  gangha  attached 
to  the  sensory  fibers  of  the  cranial  nerves,  Uke  the  Gasserian  gangHon 
of  the  fifth,  and  on  the  other  cranial  nerves  with  sensory  branches, 
from  the  fifth  cranial  to  the  seventh,  the  eighth,  the  ninth,  and  the 
tenth  cranial  nerves.  It  is  worth  noting  that  the  ganglion  on  the  sen- 
sory spinal  nerves,  Hke  all  of  them,  arises  from  cells  lying  on  the  outside 
of  the  main  axis  of  the  central  nervous  system. 

Functional  Nervous  Diseases 
epilepsy 

Nowhere,  as  in  nervous  disease,  is  the  fundamental  difference  be- 
tween functional  and  organic  derangements  in  brain  matter  so  clearly 
illustrated.  Those  due  to  demonstrable  organic  changes  always  show 
corresponding  clinical  symptoms.  Thus,  no  hemiplegic  patient,  who 
has  had  a  gross  lesion  in  one  brain  hemisphere,  ever  walks  again  as  if 
nothing  were  the  matter  with  him,  nor  does  a  man  with  tabes  fail  to 
show  it  in  his  gait. 

Not  so  with  that  functional  disease,  epilepsy.  The  most  practised 
neurologist  cannot  distinguish  beforehand  an  epileptic  in  a  company 
where  he  may  be  talking  as  usual,  until  suddenly  he  falls  in  a  violent 
convulsion.  Before  his  fit  he  may  have  gone  for  weeks  or  months 
without  a  sign  in  mind  or  body  of  his  serious  disease. 

Complete  intermission  is  a  feature  of  functional  diseases  of  far- 
reaching  significance,  because  it  shows  that  the  original  seat  of  the 
malady  is  different  from  that  of  any  affection  due  to  a  structural  de- 
rangement. Structural  derangements  in  the  body  remain  always  the 
same  and  so  do  their  effects.  Therefore,  we  must  look  elsewhere  than 
in  the  nervous  mechanism  for  the  primary  cause  of  epilepsy. 


524  CLINICAL  MEDICINE 

As  every  attack  begins  with  a  disturbance  in  some  region  of  the 
brain  cortex,  many  writers  maintain  that  an  organic  change  of  some 
kind  must  be  present  in  that  particular  region.  Thus,  malformations 
of  the  brain  itself  are  often  accompanied  with  epilepsy,  and  various 
stigmata  of  an  epileptic  constitution  are  described.  But  more  con- 
clusive still  is  the  well-known  fact  that  healthy  persons,  who  have  no 
hereditary  tendencies  to  the  disease,  become  epileptic  at  various  inter- 
vals, after  some  injury  to  the  skull,  or  even  following  the  surgical  opera- 
tion of  trephining.  In  other  cases  the  remains  of  a  venous  clot,  occur- 
ring in  the  brain  during  an  infection  like  diphtheria,  may  afterward  be 
the  origin  of  epilepsy.  These  writers,  therefore,  claim  that  epilepsy 
is  always  due  to  some  such  organic  change,  whether  this  be  discover- 
able or  not. 

But  this  view  overlooks  the  difference  between  primary  and  excit- 
ing causes.  A  primary  cause  remains  ever  the  same,  but  exciting  causes 
vary  indefinitely.  I  had  an  epileptic  who  for  years  suffered  from  fits 
till  her  mind  was  affected,  but  who  had  not  had  one  attack  for  five  years 
after  an  operation  upon  her  nose  which  I  advised.  This  nasal  trouble 
in  her,  of  course,  was  nothing  but  an  exciting  cause,  and  so  I  would 
classify  all  cases  in  which  some  intercranial  organic  lesion  appears  to 
originate  the  attack.  Those  lesions  stand  to  the  disease  in  the  relation 
of  exciting  causes  and  nothing  more.  The  primary  cause,  without 
which  the  exciting  causes  would  not  operate,  may  be  outside  the  skull, 
and  should  be  dealt  with  first. 

On  this  accoimt  the  demonstration  of  the  essential  cause  of  such  a 
functional  disease  as  epilepsy  may  be  one  of  the  most  difficult  problems 
in  pathology.  Organic  changes  are  easily  detected,  but  a  disease  which 
may  not  necessarily  be  connected  with  a  demonstrable  organic  change 
is  far  more  difficult  to  demonstrate,  and  we  have  to  decide,  first  of  all, 
what  its  essential  characters  are.  Now,  as  these  fundamental  charac- 
ters of  epilepsy  become  understood,  the  more  the  conviction  grows  that 
it  stands  alone  among  nervous  diseases,  and  does  not  share  its  chief 
factors  with  any  of  them.  The  main  question,  therefore,  is.  What  con- 
stitutes epilepsy?  What  is  the  constant  fact  in  epilepsy,  the  presence 
of  which  at  any  time,  though  it  be  quite  single  or  slight  in  its  mani- 
festation, proves  it  to  be  epilepsy,  even  if  unaccompanied  by  other 
symptoms  ordinarily  present? 

This  question  about  what  thing  is  invariable  is  all  important  in  the 
consideration  of  obscure  problems  in  medicine,  because  of  the  general 
principle  that  whatever  is  occasional  is  not  essential.  No  matter  how 
often  or  how  prominently  any  given  symptom  or  set  of  symptoms  may 


EPILEPSY  525 

occur  in  the  course  of  a  disease,  those  symptoms  cannot  be  essentially 
related  to  its  primary  cause  if  undoubted  examples  of  the  disease  occur 
without  them.  This  one  fact,  that  the  disease  can  exist  without  them, 
at  once  reduces  such  occasional  symptoms  from  the  rank  of  a  causative 
to  that  of  merely  an  accessory  relationship  to  the  disease.  In  other 
words,  symptoms  may  vary,  but  real  causes  do  not. 

Tested  by  this  principle,  epilepsy  cannot  be  defined  as  a  convulsive 
disease.  Convulsions  very  commonly  occur  in  epilepsy,  but  by  no 
means  always,  and  this  alone  proves  that  convulsions  are  only  occa- 
sional effects  and  not  inherent  elements  in  epilepsy.  As  epileptic 
convulsions  are  such  pronounced  and  terrifying  manifestations  of  the 
malady,  it  was  inferred  that  those  who  had  them  were  more  complete 
examples  of  the  disease  than  those  who  did  not  have  convulsions.  The 
old  terms  "grand  mal"  and  "petit  mal"  illustrate  this  misconception, 
attacks  of  petit  mal  being  often  spoken  of  as  mild  attacks.  I  doubt 
if  there  ever  is  a  mild  attack  of  epilepsy,  however  brief  in  duration  or 
seemingly  trivial  it  be  in  appearance.  Let  a  patient  under  treatment, 
who  seems  to  be  about  cured,  because  he  has  passed  months  without  his 
old  convulsions,  make  a  statement  that  he  just  lost  consciousness  for  a 
moment  that  morning,  but  that  it  did  not  amount  to  anything,  and 
he  discourages  the  physician.  His  patient  is  still  an  epileptic,  and 
there  never  is  an  incomplete  epileptic.  No  matter  how  mild  the  at- 
tacks seem,  they  are  wholly  unlike  mild  forms  of  any  other  nervous 
disease,  and  with  the  same  tendency  to  ultimate  grave  results  as  in 
the  most  pronounced  convulsive  forms. 

One  further  undesirable  effect  of  undue  estimation  of  the  convulsive 
element  in  epilepsy  is  its  suggestion  that  the  first  process  in  an  attack 
is  of  the  nature  of  a  sudden  hberation  of  energy  in  some  part  of  the 
brain.  Many  writers  speak  of  epilepsy  as  beginning  with  a  discharge 
of  nervous  force  in  a  cortical  area  or  center,  the  conception  evidently 
being  something  Hke  the  electric  discharge  of  a  Leyden  jar.  But 
this  conception  is  derived  only  from  the  starting  motor  phenomena 
of  a  convulsive  paroxysm.  If  attention  were  equally  directed  to  the 
symptoms  of  true  epileptic  attacks,  which  are  not  at  all  convulsive, 
this  idea  of  explosion  would  be  as  little  suggested  as  in  a  case  of  syn- 
cope. 

Again,  it  would  not  be  correct  to  define  epilepsy  as  a  cerebral  dis- 
order, producing  loss  of  consciousness,  because  loss  of  consciousness,  or 
even  interference  with  consciousness,  is  not  invariable.  I  have  pub- 
Hshed  the  case  of  a  patient,  brought  to  me  by  Dr.  Alexander  Strong,  of 
New  York,  who  would  begin  with  the  fearful  epilepsy  cry,  then  biting 


^26  CLINICAL   MEDICINE 

of  his  tongue,  followed  by  violent  general  convulsions.  He  had  two 
such  convulsions  ui  my  office  that  were  completely  typical  of  the  disease, 
but  I  found  afterward,  by  testing  him,  that  he  never  lost  consciousness 
of  what  I  was  doing  before  him.  Hence,  loss  of  consciousness,  because 
not  invariable,  is  not  essentially  related  to  epilepsy,  and  gives  no  clue 
whatever  to  the  nature  of  the  disease.  In  fact,  loss  of  consciousness 
per  se  is  the  least  helpful  of  all  symptoms  toward  affording  an  insight 
into  any  brain  process,  as  the  problem  of  common  sleep  testifies. 

If  epilepsy  were  a  disease  Hke  hysteria,  of  every  grade  of  severity, 
if  not  also  of  diverse  nature  and  kind,  m  different  patients,  we  might 
grade  the  symptoms  of  epilepsy  uito  mild  or  imimportant  and  into 
severe  or  grave  symptoms,  regarding  epilepsy  as  a  trivial  disease  in 
some  patients  and  a  grave  disease  in  others,  according  to  the  nature  of 
their  symptoms,  but  such  is  never  the  case.  A  child  three  years  old,  for 
example,  was  brought  to  me  for  what  his  parents  called  "a  caper"  of 
his — suddenly  ducking  his  head  now  and  then;  soon  they  smilingly 
told  me  to  look  for  myself,  and  see  how  he  did  it.  I  at  once  saw  that 
in  this  "caper"  his  eyes  became  fixed  and  his  pupils  dilated.  It  was  ui 
vain  that  I  tried  to  impress  the  parents  with  the  seriousness  of  the 
case,  but  in  two  years  he  became  an  idiot  and,  fortunately,  died. 

Not  to  go  further  in  this  direction,  we  would  simply  say  that  the 
fact  of  epilepsy  does  not  depend  at  all  on  the  number  or  on  the  variety 
of  the  symptoms,  but  solely  on  the  question  whether  the  symptoms  are 
epileptic  or  not.  If  epileptic,  the  symptoms  may  be  only  one  or  two 
in  number,  and  both  slight  and  temporary,  but  that  case  is  a  serious 
case  nevertheless,  quite  as  much  so  as  one  in  which  there  are  violent 
convulsions,  though  only  at  long  intervals.  The  reason  is,  that  epilepsy 
is  a  specific  disease,  and  every  case  of  it  is  a  case  of  epilepsy  and  of 
nothing  else;  no  other  disease  is  so  protean  in  the  manifestations,  and 
there  is  none  whose  manifestations  afford  so  little  clue  to  its  underlying 
cause,  for  the  most  diverse  forms  are  often  found  to  become  inter- 
changeable with  one  another.  A  non-convulsive  case  may  at  any  time 
change  into  a  convulsive  one,  or  vice  versa.  A  patient,  with  complete 
loss  of  consciousness,  may  have  attacks  in  which  consciousness  is 
preserved,  or  he  may  have  what  are  called  co-ordinated  attacks,  when 
he  walks  forth,  having  stripped  himself  stark  naked,  or  he  may  have 
an  attack  of  epileptic  mania;  this  latter  outcome  occurs  oftener  in  those 
who  have  been  subject  to  non-convulsive  attacks,  but  I  had  a  patient 
who  always  first  fell  in  strong  convulsions,  and  then  would  rise  and  rush 
to  attack  the  first  person  he  saw.  We  have  to  go  deeper,  therefore, 
than  the  varying  symptoms,  deeper  than  its  curiously  different  exter- 


EPILEPSY  527 

nal  manifestations,  in  search  of  something  which  neither  varies  nor 
differs,  but  is  always  present,  in  every  case  of  epilepsy.  If  such  an 
element  can  be  found,  we  are  then  in  line  to  approach  to  something 
fundamental  in  the  pathology  of  the  disease ;  that  there  is  such  an  ele- 
ment in  epilepsy,  an  element  that  is  foimd  in  no  other  disease,  hence  an 
element  which  is  pathognomonic,  we  will  now  demonstrate;  and  on 
that  account  we  have  directed  attention  to  the  nature  of  the  very  first 
symptom  of  the  attack,  to  show  that  it  is  as  truly  epileptic  as  any  of 
the  subsequent  ones.  In  other  words,  epilepsy  not  only  begins,  but  is 
altogether  epilepsy,  with  the  very  first  symptom.  That  first  symptom 
is  part  of  the  epileptic  process,  which  is  Hke  no  other  process,  and  needs 
nothing  to  make  it  more  complete,  even  though  it  shows  only  one  mani- 
festation and  stops  short  at  that,  Uke  the  "caper"  in  the  child  referred 
to.  That  same  first  symptom,  whatever  it  be,  is  epileptic,  and  nothing 
but  epileptic;  none  of  the  subsequent  symptoms  are  any  more  epileptic 
than  the  first  one;  it  was  pure  epilepsy  from  the  start,  just  as  fire  is 
nothing  but  fire,  whether  in  the  flame  of  a  match  or  in  the  subsequent 
flames  of  a  buHding,  first  Ht  by  the  match.  We  shall  gain  a  correct 
insight  into  this  disease  when  we  recognize  that  the  first  symptom  is 
the  most  important  symptom  of  all,  because  of  its  pointing  to  the  one 
constant  element  in  epilepsy,  that  element  which  is  never  absent  in 
any  of  its  attacks,  and  which,  in  short,  makes  it  epilepsy. 

That  never  varying  element  in  epilepsy  is  suddenness.  Epilepsy  is 
the  only  sudden  disease;  other  diseases  may  be  rapid  in  their  onset,  but 
none  are  sudden  except  epilepsy.  The  first  onset  is  always  instantane- 
ous, and  this  fact  furnishes  the  most  important  clue  to  the  nature;  nor 
is  this  statement  altered  by  the  sometimes  prolonged  and  far-distrib- 
uted disturbances  which  follow  that  sudden  onset,  any  more  than  one 
could  say  when  a  dam  gives  way  that  the  greatness  of  the  consequent 
ruin  precludes  the  explanation  that  it  started  with  a  small  leak  in  the 
wall;  it  was  an  insignificant  run  of  water  in  the  beginning  and  a  deluge 
at  the  end,  but  it  was  water  all  the  same,  and  water  only,  which  did 
it  from  first  to  last,  so  the  whole  outburst  of  an  attack  of  grand  mal 
should  not  confuse  us,  either  by  its  violence  or  by  its  duration,  from 
recognizing  its  oneness  with  the  gentle  ascending  aura  which  with  it 
instantaneously  began.  Or,  we  might  illustrate  it  thus,  no  one  stone 
in  an  arch  is  ever  isolated  or  independent  of  the  others,  but  both  re- 
ceive something  from,  and  give  something  to,  the  whole  arch;  but  let 
one  of  the  stones  of  the  arch  be  suddenly  loosened,  then  a  great  com- 
motion follows  in  the  whole  arch,  not  because  the  arch  has  received  a 
great  shock  or  impulse  from  without,  least  of  all  because  the  arch  was 


528  CLINICAL  MEDICINE 

composed  of  explosive  materials,  but  simply  because  a  long-standing, 
inherent  force  in  it— namely,  that  of  gravitation,  for  distributing  which, 
in  a  certain  way,  the  arch  has  been  constructed — has  been  suddenly 
liberated  from  its  normal  restraints  by  an  abnormal  change  of  place  in 
a  single  stone.  Or,  to  use  another  illustration,  the  propeller  of  a  steamer 
is  fashioned  first,  and  then  the  power  is  communicated  to  it  to  act  against 
the  mighty  restraint  of  the  water  in  which  it  is  immersed.  Once  on  a 
steamer,  as  I  sat  reading  in  the  cabin  just  over  the  propeller,  the  vessel 
rose  so  that  the  propeller  for  the  moment  beat  the  air  instead  of  the 
water;  the  whole  vessel  at  once  seemed  to  have  a  violent  epileptic  fit, 
which  shook  it  from  end  to  end;  but  all  this  was  not  on  account  of  a 
new  spontaneous  burst  of  steam  from  the  boiler,  it  was  only  the  old 
normal  energy  acting  with  the  old  normal  inhibition  suddenly  with- 
drawn. These  two  illustrations  of  disturbance  in  physical  mechanisms 
by  derangements  of  regulated  physical  inhibition  may  now  be  properly 
appHed  to  derangements  of  regulated  inhibition  between  the  various 
nervous  centers  in  the  brain  cortex.  No  functions  of  a  nervous  kind 
are  ever  performed  independently,  but  only  under  regulated  inhibi- 
tion by  other  nervous  functions;  if  it  were  not  for  regulated  inhibition 
between  different  nerve-centers  all  would  be  chaos;  thus,  there  can  be 
no  general  nervous  stimulant,  because  when  the  flexor  muscles,  for 
example,  are  stimulated  to  action  the  corresponding  extensor  muscles 
must  relax.  Nerve-cells  store  up  within  themselves  nerve  energy,  but 
this  energy  never  explodes  spontaneously.  Hence,  how  does  nerve 
energy  act?  Always  according  to  the  first  law  in  the  physiology  of  the 
nervous  system,  which  is,  that  the  beginning  of  every  nervous  act  is  in- 
variably on  the  afferent  side.  A  spontaneous — that  is,  a  primary  motor 
or  efferent — discharge  is  unknown;  all  efferent  phenomena  are  in  re- 
sponse to  previous  afferent  excitation  and  to  nothing  else.  Why,  there- 
fore, should  it  occur  without  an  afferent  excitation  in  epilepsy?  How- 
ever explosive  a  nervous  discharge  may  seem  to  be,  still  it  is  by  some 
afferent  train  that  the  explosive  was  lit. 

On  these  lines  my  definition  of  epilepsy  would  be  this:  Epilepsy 
is  a  disease  characterized  by  a  sudden  derangement  of  the  normal  regula- 
tive inhibition  existing  between  cortical  nerve-centers,  induced,  in  the  first 
instance,  by  an  abnormal  afferent  excitation. 

This  statement  of  the  pathology  of  epilepsy  shifts  the  primary  seat 
of  the  disease  from  the  motor  or  efferent  to  the  sensory  or  afferent 
portions  of  the  nervous  structures  involved,  and,  by  so  much,  affects 
all  the  problems  connected  with  the  treatment  of  the  disease.  That  the 
afferent  origin  of  epilepsy  is  no  theory  is  proved  by  the  multitude  of 


EPILEPSY  529 

instances  in  which  every  one  admits  that  the  disease  is  caused  solely 
by  some  afferent  irritation.  Thus,  some  epilepsies  have  been  caused  by 
the  irritation  of  a  thickening  in  the  nose,  or  by  a  tapeworm  in  the  in- 
testines, or  by  a  stone  in  the  kidney,  and  have  been  cured  by  the  re- 
moval of  these  sources  of  afferent  excitation.  But  some  writers,  under 
the  theory  that  epilepsy  is  due  to  instability  of  the  motor  centers, 
try  to  make  these  epilepsies  of  plainly  afferent  origin,  a  class  by  them- 
selves, and  call  them  "reflex"  epilepsies,  while  all  other  forms  they  term 
"idiopathic"  epilepsies,  which  they  tell  us  are  of  central  origin.  The 
term  "idiopathic"  is  itself  a  confession  of  theory;  but,  when  this  theory 
assumes  that  the  efferent  phenomena  are  spontaneous  and  idiopathic, 
while  not  a  single  example  can  be  adduced  of  eflferent  activity  without 
its  antecedent  afferent  excitation,  this  view  is  simply  impossible.  This 
most  sepecific  disease  has  but  one  mechanism  and  is  always  reflex,  and 
in  every  case  our  problem  is  to  find  what  the  afferent  source  of  the 
trouble  is. 

Treatment. — We  should  always  begin  with  a  careful  examination 
of  the  patient  all  over,  to  search  for  the  possible  existence  of  some 
one  source  of  abnormal  afferent  excitation.  Such  a  cause  is  too  often 
found  in  an  intercranial  focus  of  irritation  following  upon  an  injury  to 
the  head.  The  history  of  a  severe  fall,  it  may  be  years  before,  is  alw^ays 
worth  noting,  but,  in  my  experience,  the  same  organic  cause  of  an  inter- 
cranial irritation  can  be  found  the  sequel  of  a  venous  thrombosis  in  the 
meninges  occurring  in  the  course  of  one  of  the  specific  fevers,  such  as 
typhoid  fever.  One  of  the  most  curious  instances  of  the  kind  occurred 
to  me  in  a  middle-aged  woman  after  an  attack  of  diphtheria.  The 
history  of  an  attack  of  sunstroke  is  also  not  an  uncommon  antecedent. 
This  entire  class  of  epileptics  often  admit  sensations  of  discomfort 
about  the  head  on  barometric  changes  in  the  weight  of  the  atmosphere 
presaging  a  storm,  or  exposure  to  the  hot  sun.  I  always  prescribe  for 
such  patients,  in  connection  with  other  remedies,  a  long-continued 
dosing  with  ^V  g^.  of  mercury  biniodid,  three  times  a  day,  and  the 
application  to  the  mastoid  processes  and  nape  of  the  neck  of  the  bin- 
iodid ointment,  according  to  the  recommendation  of  Dr.  Fuller,  of  the 
London  Hospital,  many  years  ago  before  the  bromids  were  thought  of. 

One  of  the  most  curious  of  the  vagaries  of  epileptic  attacks  occurs 
when  the  primary  focus  of  irritation  is  in  the  nose;  they  are  always 
associated  with  growths  or  thickenings  which  cause  pressure  on  the 
ethmoid.  Vertigo  is  a  frequent  symptom  of  these  cases,  with  ringing 
in  the  ears  and  sensitiveness  to  sound.  The  coma  following  the  at- 
tacks is  sometimes  quite  pronounced;  a  tendency  to  weep  and  loss  of 
34 


53©  CLINICAL   MEDICINE 

memory  are  very  common,  but  it  is  remarkable  how  promptly  and 
permanently  many  of  these  patients  are  relieved  by  slight  opera- 
tions on  the  nose.  When  we  consider  how  intimately  the  nose  is 
associated  with  the  respiratory  nervous  mechanism  in  the  medulla, 
often  illustrated  in  the  causation  of  asthma,  the  further  implication 
of  those  centers  by  similar  complications  in  the  upper  nasal  passages 
becomes  quite  probable,  and  should  lead  to  careful  examination  of 
those  passages  in  every  epileptic. 

The  greatest  area  of  reflex  excitability,  however,  in  the  whole  body 
is  in  the  throat,  just  at  the  crossing  of  the  tracts  of  respiration  and  of 
deglutition.  The  nervous  mechanism  which  presides  there  over  mus- 
cular movements  may  be  likened  to  that  of  a  railroad  switch,  because 
it  is  ever  summoned  instantly  to  prevent  anything  which  is  to  be 
swallowed  from  going  down  the  wrong  way  into  the  larynx;  rapid  eat- 
ing and  drinking,  therefore,  keeps  that  nervous  mechanism  in  a  con- 
stant state  of  excitement,  and  I  have  met  with  many  cases  in  whom  the 
first  epileptic  attack  was  caused  by  their  habitual  hurry  in  this  respect. 
Nothing  is  more  common  than  to  find  excitability  in  the  throats  of  epi- 
leptics. I  have  no  doubt  that  their  common  habit  of  bolting  their 
food  before  it  has  been  sufficiently  masticated  is  often  due  to  their 
inability  to  keep  from  swallowing  so  soon  as  a  morsel  passes  near  the 
posterior  surface  of  the  tongue.  I  would  recommend  in  such  patients 
the  application  to  the  whole  pharynx  of  a  solution  of  silver  nitrate, 
lo  gr.  to  the  ounce,  once  a  week,  and,  after  a  time,  the  tincture  of  iodin 
instead. 

The  gastro-intestinal  tract  is  well  known  as  the  seat  of  afferent 
irritations  whose  radiations  may  be  wide  enough.  We  need  not  be  sur- 
prised, however,  that  the  precise  focus  here  may  elude  our  search,  be- 
cause a  large  proportion  of  them  may  start  from  some  hidden  branch 
in  the  great  distribution  of  the  vagus.  Sometimes  the  characters  of 
an  aura  may  afford  a  probable  clue  here,  as  they  may  do  on  further 
investigation  in  intercranial  cases,  but  the  whole  mechanism  of  auras 
needs  more  study  than  has  been  given  to  it.  In  all  epileptics  troubled 
with  constipation  I  prescribe  the  constant  use  of  belladonna. 

On  the  other  hand,  the  transmission  of  a  normal  afferent  impression 
frequently  can  be  prevented  or  turned  aside,  so  to  speak,  by  an  arti- 
ficially induced  counter-impression.  Acting  on  this  principle,  I  have 
for  many  years  employed  the  red-pepper  pack  to  the  whole  surface  of 
the  body,  of  an  infusion  of  the  strength  of  i  dram  to  the  pint  of  boil- 
ing water,  and  applied  imtil  the  whole  skin  is  reddened.  At  one  of  my 
clinics  I  had  a  confirmed  case  of  a  boy,  aged  ten  years,  who  had  daily 


EPILEPSY  531 

attacks.  I  told  the  class  that,  to  test  the  effects  of  this  measure,  I 
would  give  no  medicine,  but  would  prescribe  the  pack,  with  directions 
to  the  mother  to  report  at  the  end  of  the  week  on  the  number  of  fits. 
She  did  not  return  for  five  weeks,  and  explained  her  absence  by  saying 
he  had  not  had  a  fit  until  the  previous  day.  Medicinally,  the  action 
of  our  most  widely  accepted  remedies  would  seem  of  itself  decisive  as 
to  the  primary  afferent  seat  in  the  nervous  system  of  the  disease. 
Thus,  the  bromids,  according  to  the  universal  consensus  of  experiment- 
ers, act  upon  the  peripheral  sensory  apparatus  exclusively  when  ad- 
ministered to  animals  in  doses  corresponding  to  therapeutic  doses  in 
man.  Under  their  influence  a  rabbit  may  have  its  reflex  excitability 
wholly  aboUshed,  and  yet,  when  alarmed,  it  jumps  vigorously,  thus 
proving  that  its  cortical  efferent  functions  are  intact.  In  man,  if  a 
patient  shows  such  excessive  excitability  in  his  pharynx  that  you  can- 
not touch  it  with  the  mirror  of  the  laryngoscope,  a  dose  of  30  gr.  of 
potsasium  bromid  will  soon  enable  you  to  make  the  examination  with- 
out trouble. 

The  bromids,  however,  are  too  often  administered  very  carelessly, 
just  as  though  they  were  specifics  for  every  case;  but,  as  they  have  to 
be  administered  in  free  doses  for  long  periods,  for  two  years  at  least,  we 
should  never  forget  that  they  are  unnatural  to  the  body,  and,  therefore, 
sooner  or  later,  they  wifl  act  as  poisons.  As  soon  as  they  do  so,  which 
is  shown  by  the  specific  poisonous  s3anptoms  known  as  bromism,  they 
rapidly  lose  their  remedial  properties;  it  is  our  duty,  therefore,  to 
postpone  bromism  as  long  as  possible  by  careful  attention  to  the  general 
health  of  the  patient,  and  by  counteracting  the  deleterious  influence  of 
the  drug  on  the  blood.  For  this  purpose  I  would  strongly  advise  the 
administration  of  cod-liver  oil  and  the  preparations  of  phosphorus 
along  with  the  bromids. 

There  is  no  reason  why  the  peripheral  sedative  effects  of  the 
bromids  should  not  be  reinforced;  failure  with  them  is  like  failure  with 
quinin  in  ague,  sometimes  real,  but  oftenest  owing  to  faulty  admmis- 
tration. 

Experience  has  also  shown  that  antipyrin  and  phenacetm  are  valu- 
able adjuvants  to  the  bromids.  Antipytin  may  be  given  in  lo-gr. 
doses  and  phenacetin  in  doses  of  from  10  to  20  gr.  with  each  dose  of 
the  bromids.  The  ammonium  bromid  appears  to  be  the  preferable 
salt  in  such  combinations.  When  the  attacks  are  nocturnal,  chloral 
is  also  indicated,  and  may  be  taken  in  doses  of  10  gr.  at  bedtime. 

The  great  aim,  however,  in  the  treatment  of  epilepsy  is  prophylaxis. 
Anything  which  increases  the  uitervals  between  the  attacks  is  so  much 


532  CLINICAL  MEDICINE 

gain  against  the  evil  of  pernicious  habit.  Mere  routine  administra- 
tion of  drugs  and  undue  reliance  on  them  alone  is  the  chief  cause  of 
want  of  success  in  the  treatment  of  this  deeply  seated  disease.  An  epi- 
leptic should  always  be  regarded  as  having  a  profoundly  defective  con- 
stitution, and  no  measure  should  be  neglected  to  discover  any  cause  of 
ill  health  in  him.  Now  one  of  the  commonest  causes  of  ill  health  is 
toxemia  from  auto-infections.  Blood-poisons  may  at  any  time  of  life 
cause  a  person  to  acquire  epilepsy ;  these  attacks  are  then  often  termed 
"epileptiform,"  but  there  is  no  such  thing  as  an  epileptiform  convul- 
sion, even  in  infants.  These  attacks  are  just  as  typical  in  their  cHnical 
accompaniments  as  any  attack  of  grand  mal,  with  the  same  bituig  of 
the  tongue,  clonic  spasms,  and  subsequent  coma,  and  all  the  other 
details  that  ever  occur  in  an  epileptic  paroxysm.  The  toxemia  which 
produces  them  may  be  temporary,  but  that  does  not  alter  the  nature  of 
the  attacks  themselves.  All  that  is  needed  to  have  them  graduate  into 
the  full  degree  and  letter  of  epilepsy  is  to  have  them  occur  often  enough 
to  estabUsh  the  epileptic  habit.  That  they  often  do  so,  in  the  case  of 
infantile  convulsions,  is  well  known.  And  the  reason  why  epilepsy 
is  more  difficult  to  cure  the  younger  the  patient,  is  because  that  is  the 
age  for  easily  contracting  life-long  habits  of  every  kind. 

It  is  in  the  gastro-intestinal  tract  that  the  source  of  the  commonest 
infections  is  to  be  found.  Hence,  the  prime  importance  of  diet  in  the 
treatment  of  this  disease.  I  always  tell  patients  that  they  cannot  get 
well  if  they  continue  to  be  hearty  meat  eaters.  Thus,  carnivorous 
animals,  when  they  die  from  natural  causes,  die  most  commonly  from 
epilepsy,  and  the  difference  between  them  and  the  herbivora  in  prone- 
ness  to  convulsive  attacks  is  known  to  all.  So  far  as  my  experience 
goes,  a  return  of  the  disease  has  been  too  often  the  case  in  patients  who 
have  resumed  a  meat  diet  to  make  me  doubt  the  reason.  I  have  a 
striking  illustration  of  this  in  the  case  of  32  epileptic  inmates  in  the 
hospital  for  the  insane,  Ward's  Island,  N.  Y.  I  had  regulated  their 
diet  by  cutting  out  all  meat  for  some  months,  until  Thanksgiving  Day, 
1907,  when  I  was  petitioned  to  allow  them  to  have  the  usual  Thanks- 
giving dinner;  this  they  partook  of  very  heartily,  with  the  result  that 
30  of  the  32  had  a  return  of  their  epileptic  attacks  the  very  next  day. 
Moreover,  everything  indigestible,  whether  on  general  or  personal 
grounds,  should  be  avoided  by  the  patient,  particularly  at  the  evening 
meal. 

Intestinal  antiseptics  are  always  prescribed  by  me,  sooner  or  later, 
in  treatment,  particularly  if  a  bad  breath  accompanies  or  follows  the 
attacks,  and  also  in  those  cases  characterized  by  attacks  coming  in 


INFANTILE   CONVULSIONS  533 

groups.  The  best  intestinal  antiseptic  that  we  possess  is  a  calomel 
purgative,  consisting  of  5  gr.  of  calomel  and  35  gr.  of  compound  jalap 
powder,  to  be  given  once  or  twice  a  week,  and  to  be  followed  by  10  gr.  of 
the  benzoate  and  10  gr.  of  the  saHcylate  of  soda,  an  hour  after  each  meal. 
After  an  experience  of  fully  forty  years  in  the  treatment  of  this 
disease  I  would  state  the  prognosis  for  complete  cure,  in  average  cases, 
to  be  quite  70  per  cent.  The  chief  reason  why  the  percentage  of  actual 
cures  does  not  ordmarily  reach  that  figure  is  owing  to  the  difficulty  of 
getting  the  patient  to  persevere  in  the  whole  details  of  the  course;  after 
a  more  or  less  prolonged  freedom  from  the  attacks,  they  grow  careless 
and  neglectful.  They  should  be  enjoined  to  regard  themselves  as  still 
epileptics  until  at  least  fully  two  years  have  lapsed  from  the  last  sign 
of  an  attack,  and  after  that  they  must  for  hfe  continue  to  be  cautious 
in  their  conduct.  Still  there  remain  those  in  whom  the  epileptic  habit 
has  been  engrafted  upon  a  poor  constitution  from  youth;  but  even  in 
these,  it  is  encouraging  to  know  that  many  of  them  can  be  cured  alto- 
gether, as  I  know  personally  to  have  occurred  in  a  number  who  have 
been  under  my  observation  from  ten  to  more  than  twenty  years. 

CATALEPSY 

Cataleptic  attacks  are  not  unknown  in  hysteria,  which  disease  may 
imitate  anything,  but  a  true  instance  of  catalepsy  I  have  seen  but  once, 
and  that  in  a  man  who  was  brought  by  two  policemen,  who  found  him 
sitting  on  a  bench  near  the  Central  Park.  As  the  pohceman  thought 
his  posture  strange,  he  asked  him-  what  was  the  matter,  but,  though 
the  man  seemed  conscious,  he  did  not  speak.  The  pohceman  then 
partly  raised  him  from  his  seat,  but  on  letting  go  he  remained  in 
that  posture.  He  then  raised  one  hand  partly  above  his  head,  and 
it  stayed  put;  the  same  way  with  the  leg  on  the  opposite  side.  Putting 
him  in  an  ambulance,  they  took  him  to  the  Roosevelt  Hospital,  where 
the  house  staff  were  equally  puzzled  with  him,  because  he  seemed  to 
be  a  perfect  manikin.  I  then  happened  to  drive  up  in  my  carriage,  and 
began  to  examine  him  myself.  Just  as  one  of  the  pohcemen,  with 
bated  breath,  asked  me  if  he  were  "possessed,"  I  answered  that  he  was, 
but  that  we  would  soon  dispossess  him,  and  ordered  that  a  cold  steel 
sound  be  passed  into  his  bladder.  This  procedure  immediately  brought 
him  out  of  his  condition,  and  he  soon  left  the  hospital  apparently  as 
normal  as  ever. 

INFANTILE  CONVULSIONS 

Epileptiform  convulsions  are  very  common  in  children,  owing  to 
the  disproportionate  development  of  the  braui  in  childhood.     A  not- 


534 


CLINICAL   MEDICINE 


able  rise  in  the  temperature  of  the  blood  at  the  onset  of  the  specific 
fevers,  such  as  in  pneumonia  and  scarlet  fever,  predisposes  to  such  con- 
vulsions. One  of  the  commonest  causes  of  such  attacks  is  from  de- 
rangements in  the  ahmentary  canal,  whether  from  improper  diet  or 
overfeeding.  The  indication  then  is  to  remove  the  offending  materials 
by  a  dose  of  castor  oil. 

We  should  be  particularly  careful  to  forestall  the  formation  of  the 
epileptic  habit,  because  many  cases  of  epilepsy  in  after  years  have  a 
history  of  frequent  infantile  convulsions  in  the  first  to  the  third  year 
of  hfe. 

Treatment. — The  principles  of  treatment,  however,  do  not  differ 

from  those  which  we  have  already  detailed  for  the  management  of 

epilepsy  itself,  other  than  their  modification  according  to  the  age  of 

the  patient. 

VERTIGO 

Following  naturally  upon  the  consideration  of  epilepsy  comes  the 
subject  of  vertigo.  Not.  that  there  is  any  relation  between  these  two 
disorders,  but  because  in  vertigo  we  have  the  most  striking  illustra- 
tions that  we  are  physically  directed  by  the  afferent  element  in  the 
nervous  system,  that  element  which  is  so  often  overlooked  in  the  study 
of  epilepsy. 

How  do  we  maintain  our  balance  when  we  stand?  By  a  constant 
exercise  of  the  motor  or  efferent  nerves  of  our  muscles.  A  great  array 
of  actively  contracting  muscles  work  together  to  keep  us  erect  while  we 
stand,  and  to  prevent  us  from  staggering  when  we  walk.  All  this  is 
due  to  unremitting  efferent  activity,  and,  at  first  sight,  seems  to  show 
that  the  efferent  is  the  dominating  power  in  the  nervous  system. 
But  the  first  case  of  vertigo  shows  that  this  is  a  mistake.  No  efferent 
action  occurs  without  an  afferent  excitation  precedes  it. 

The  whole  great  array  of  muscles  concerned  in  maintaining  the 
body  in  equilibrium  can  be  distributed  in  their  action  by  lack  of  infor- 
mation from  the  afferent  sources  of  the  eyes,  of  the  semicircular  appa- 
ratus of  the  internal  ear,  or  from  suspension  of  the  muscular  sense. 

Thus,  as  to  the  eyes,  I  once  climbed  the  Great  Pyramid  in  Egypt,  to 
find  that  when  I  reached  the  great  stone  on  top,  although  it  offered  a 
surface  of  some  twenty  feet  square  to  stand  upon,  I  could  not  do  it, 
but  forthwith  sat  down,  because  all  the  muscles  of  my  legs  were  in  a 
state  of  helpless  tremor.  This  was  not  at  all  from  fatigue,  but  simply 
because  my  eyes,  for  the  first  time,  were  looking  into  nowhere  which- 
ever way  I  turned,  and,  therefore,  could  not  tell  my  leg  muscles  what 
to  do.     Just  the  same  kind  of  dizziness  occurs  to  many  persons  as  they 


VERTIGO  535 

stand  on  the  brink  of  a  precipice,  though  here  the  lack  of  afferent  im- 
pressions is  only  half  in  its  extent  compared  with  what  it  is  on  the 
pyramid. 

The  mental  condition  at  such  times,  as  it  is  in  all  vertigos,  is  that 
of  great  alarm  from  fear  of  falling.  This  is  so  instinctive  that  there  is 
no  use  trying  to  overcome  it. 

But  the  worst  sensation  of  vertigo  comes  from  disturbance  of 
afferent  impressions  in  that  remarkable  apparatus  for  maintaining  equi- 
librium, the  labyrinth  of  the  internal  ear.  Here  are  three  tubes  con- 
taining fluid,  which  cross  one  another  according  to  the  three  dimensions 
of  space,  and  the  movements  of  that  fluid  tell  the  cerebellum  how  the 
center  of  gravity  is  affected  by  every  bodily  movement.  Any  accident 
to  these  tubes,  whether  from  external  violence  or  from  hemorrhage  into 
them,  produces  a  most  dreadful  sensation,  which,  indeed,  may  be  fol- 
lowed by  death. 

Muscular  sensations  may  be  suspended  by  disease  or  by  poisons. 
A  familiar  example  of  the  latter  is  afforded  by  alcohol,  which  has  the 
property  of  paralyzing,  not  the  efferent  muscular  action,  but  the  affer- 
ent sense  in  the  muscles  themselves.  The  effect  is  that  the  dnmkard  is 
distressed  with  an  ignorance  of  the  whereabouts  of  his  legs,  and,  there- 
fore, staggers,  but  a  like  suspension  of  the  muscular  sense  occurs  in 
disease,  as  in  tabes,  giving  to  this  complaint  the  name  of  locomotor 
ataxia. 

The  auditory  or  eighth  cranial  nerve  when  it  enters  the  skull  is 
composed  of  two  parts,  which  differ  wholly  in  function  from  each  other. 
The  first  division,  or  the  auditory  nerve  proper,  goes  to  the  cochlea,  to 
be  there  finally  distributed  to  the  organs  of  Corti,  which  is  the  appa- 
ratus for  hearing.  The  second  is  the  vestibular  nerve,  which  primarily 
has  nothing  to  do  with  hearing,  but  is  the  nerve  for  equilibrium.  Its 
distribution  is  largely  in  the  semilunar  canals. 

The  vestibular  nerve  enters  directly  the  lateral  side  of  the  pons 
and  terminates  in  two  groups  of  cells,  the  cells  of  Deiters  and  Bechterew's 
nucleus,  and  the  cells  of  the  posterior  nucleus,  lying  upon  the  floor  of 
the  fourth  ventricle.  The  cells  of  Deiters'  nucleus  form  the  most 
remarkable  set  of  coimections  in  the  body,  especiaUy  with  the  cere- 
bellum, that  great  organ  of  muscular  co-ordination,  with  the  nuclei 
of  the  oculomotor  nerves,  the  sixth,  fourth,  and  third,  with  various 
nuclei  of  the  tegmentum,  and  with  the  olivary  bodies.  Some  fibers 
of  Deiters'  nucleus  pass  downward  to  the  nuclei  of  the  cervical  nerves 
of  the  spinal  cord,  and  connect  with  the  motor  nuclei  of  the  head  and 
back.     The  posterior  nucleus  of  the  vestibular  nerve  connects  not  only 


536  CLINICAL  MEDICINE 

with  the  most  important  parts  of  the  cerebellum,  but  also  with  the 
upper  portion  of  the  brain  axis,  the  corpora  quadrigemina,  corpora 
geniculata,  and  the  optic  thalami. 

We  can  well  imderstand,  therefore,  how  serious  must  be  the  results 
of  any  widespread  disturbance  of  these  great  afferent  nerve-centers. 
Vertigo,  thus  produced,  is  accompanied  by  great  mental  terror  and 
vomiting,  with  rapid  action  of  the  heart,  relaxation  of  the  blood- 
vessels, with  sweating  and  great  faintness.  This  is  well  illustrated  in 
Meniere's  disease,  caused  by  hemorrhage  into  the  semicircular  canals. 
This  may  occur  suddenly  in  perfect  health,  or,  more  commonly,  be 
preceded  by  ear  disease  or  by  arteriosclerosis.  It  may  be  followed  by 
permanent  deafness.  Any  mental  exertion  may  bring  on  an  attack, 
so  that  the  patient  lives  in  constant  terror  of  them.  I  once  had  a  well- 
known  clerg5mian  who  consulted  me  about  them,  and  I  could  not  help 
pitying  him  in  his  distress.  He  finally  died  in  one  of  these  paroxysms. 
Nystagmus,  or  rolling  of  the  eyeballs,  is  a  common  accompaniment. 

Treatment. — The  treatment  of  vestibular  vertigo  is  by  absolute 
and  prolonged  rest  in  bed  and  by  blisters  behmd  the  ear,  along  with 
doses  of  15  to  20  gr.  of  strontium  bromid,  with  10  gr.  of  chloral,  an 
hour  after  meals  and  at  night,  while  the  only  nutritive  administrations 
should  be  a  wineglassful  dose  of  equal  parts  of  milk  and  lime-water 
every  two  hours. 

Babinski  and  Putnam  have  advised  lumbar  puncture  in  treatment 
of  all  vertigo,  and  report  success.  From  10  to  15  c.c.  of  spinal  fluid  is 
withdrawn,  and  after  a  week  this  has  to  be  repeated  if  necessary. 

Voltolini  has  reported  an  affection  which  he  considers  due  to  pri- 
mary inflammation  of  the  labyrinth.  This  disease  occurs  mostly,  but 
not  always,  in  children.  Like  acute  meningitis,  it  begins  suddenly 
with  high  fever,  delirium,  vomiting,  and  vertigo.  After  a  few  days 
these  symptoms  subside,  but  the  child  still  suffers  from  dizziness  and 
staggers  in  walking,  while  it  is  found  to  be  deaf.  The  staggering  grad- 
ually passes  off,  though  some  degree  of  deafness  remains.  The  lesions 
found  have  been  plastic  exudations,  with  destructive  processes  in  the 
semilunar  canals. 

The  treatment  should  be  by  counterirritation  about  the  ears,  pur- 
gatives, and  bromids  in  large  doses. 

Vertigo  may  be  caused  by  trauma  of  the  vestibular  nerve.  Thus, 
Starr  ("Nervous  Diseases,"  page  849)  records  the  case  of  a  fireman, 
seen  at  the  New  York  Hospital,  who  by  a  fall  had  fractured  the  base  of 
his  skull  and  torn  the  left  auditory  nerve.  This  caused  an  absolute 
deafness  in  the  left  ear,  a  constant  agonizing  sensation  of  the  rotation 


VERTIGO  537 

of  the  body  in  its  longitudinal  axis.  Unless  firmly  held  this  man  con- 
stantly revolved  upon  his  bed,  complaining  all  the  time  of  the  most 
intense  distress.  His  vertigo  was  attended  by  extreme  exhaustion, 
vomiting,  rapid  pulse,  and  in  three  days  he  died  from  heart  failure. 

Vertigo  is  a  frequent  symptom  in  diseases  of  the  pons  varolii.  Thus 
tumors  upon  the  base  of  the  brain,  syphilitic  exudations,  or  vascular 
lesions  in  the  pons  and  abscesses  or  tumors  in  the  cerebellum  irritate  or 
destroy  the  vestibular  nerve  or  its  nuclei.  The  vertigo  is  by  no  means 
so  severe  as  in  Meniere's  disease,  but  is  shown  by  a  tendency  to  stagger 
to  one  side.  In  such  cases  the  presence  of  other  cranial  nerve  symp- 
toms usually  aid  in  the  diagnosis. 

Vertigo  is  sometimes  caused  by  accumulations  in  the  external 
auditory  canal,  which  produce  pressure  upon  the  tympanum  that  is 
transmitted  by  the  ossicles,  which  connect  the  tympanum  with  the 
fenestrum  ovalis.  This  pressure,  therefore,  may  be  thus  transmitted 
through  the  fenestrum  ovaHs  to  the  fluid  contained  in  the  semicircular 
canals  of  the  labyrinth,  sufficient  to  cause  both  vertigo  and  staggering. 

I  once  had  a  man  brought  to  my  clinic  with  the  diagnosis  of  loco- 
motor ataxia  because  he  staggered  so.  On  examining  his  ears  I  said 
that  we  would  cure  this  locom'otor  ataxia  then  and  there  by  a  basin  of 
water,  because  his  ears  were  stuffed  with  hardened  wax.  After  pro- 
longed syringing  the  wax  was  removed,  and  he  walked  out  with  no 
more  ataxia.  But  pressure  of  this  kind  can  be  caused  by  any  affections 
of  the  middle  ear,  such  as  by  accumulation  of  pus  or  blood  in  the  middle 
ear,  and  are  to  be  treated  by  incision  into  the  tympanum.  Vertigo 
may  also  be  a  comparatively  trivial  trouble,  caused  by  arteriosclerosis, 
and  is,  therefore,  not  uncommon  in  elderly  persons,  particularly  on  their 
sudden  rising  or  even  while  walking.  In  such  cases  the  arteries  are  to 
be  carefully  examined,  and  if  signs  of  arteriosclerosis,  with  high  tension, 
are  present  in  them  they  should  be  treated  with  from  lo  to  15  drops  of 
the  tincture  of  aconite  four  times  a  day,  coupled  with  15-gr.  doses  of 
strontium  bromid. 

Vertigo  is  not  uncommon  in  functional  derangements  of  the  ali- 
mentary canal,  the  accumulation  of  gas  with  hyperchlorhydria  in  the 
stomach  often  causing  dizziness,  which  may  be  relieved  at  once  by  a 
teaspoonful  of  aromatic  spirits  of  ammonia  in  a  wineglassful  of  water. 
This  causes  eructation  of  the  gas  and  counteracts  the  acidity  with 
speedy  relief.  Some  disturbances  in  the  lower  intestine  also  cause 
momentary  but  severe  vertigo,  with  a  tendency  to  fall  forward.  This  is 
due  to  fermentation  in  the  intestine,  and  is  quickly  relieved  by  10  gr. 
of  urotropin  with  10  gr.  of  benzoate  of  soda.     All  these  forms  recently 


538  CLINICAL  MEDICINE 

mentioned  of  vertigo  do  not  cause  any  pain  in  the  ear  or  deafness,  and, 

least  of  all,  vomiting. 

HYSTERIA 

Our  composite  nature  is  made  up  chiefly  of  two  elements — the 
intellectual  and  the  emotional — and  persons  differ  from  each  other 
according  to  the  predominance  of  one  or  the  other  element.  This 
becomes  all  the  more  apparent  in  morbid  conditions.  Hysteria  may 
be  defined  as  a  state  similar  to  that  of  a  person  who,  we  say,  is  carried 
away  by  his  emotions.  It  is,  therefore,  much  more  common  in  women, 
though  men  are  by  no  means  exempt.  It  is  also  more  prevalent  among 
Latin  than  Teutonic  races.  The  parallels  between  emotional  and 
hysteric  states  are  numerous.  Thus,  under  strong  emotion  the  voice 
trembles  or  even  becomes  abolished,  and  aphonia  is  a  well-known 
accompaniment  of  hysteria.  I  have  known  strong  emotion  to  suspend 
the  sensation  of  pain;  for  example,  in  my  experience  more  than  one 
soldier  in  battle  was  wholly  unaware  of  the  reception  of  a  serious 
wound.  Similarly,  areas  of  anesthesia  of  the  skin  are  well  known  some- 
times in  hysteria.  The  emotion  of  fear  may  temporarily  paralyze  the 
leg,  and  just  such  paralyses  occur  in  hysteria.  As  we  proceed  we  shall 
find  so  many  other  parallels  between  emotional  and  actual  hysteric 
states  that  we  might  truly  say  that  a  hysteria  is  a  condition  of 
diseased  emotional  excitabihty.  This  principle  has  much  to  do  with 
the  treatment.  Thus,  a  person  may  keep  his  thoughts  to  himself,  but, 
unless  endowed  with  a  strong  will,  cannot  escape  showing  his  emo- 
tions. In  hysteria  the  will  is  weak  and  the  emotions  rule,  but,  as  the 
emotions  crave  company,  so  a  hysteric  cannot  abide  being  alone. 
Moreover,  there  is  nothing  worse  in  the  management  of  a  hysteric 
person  than  manifestations  of  sympathy,  and  many  a  hysteric  girl 
cannot  be  cured  until  she  is  deprived  of  the  sympathy  of  her  mother 
or  other  members  of  the  family  by  removal  from  home. 

The  rule  in  hysteria  is  that  it  especially  prevails  in  neuropathic 
families  who  are  easily  swayed  by  their  feelings,  and  who  are  not  prop- 
erly trained  in  self-restraint.  It  cannot  be  too  clearly  emphasized  that 
hysteria  and  a  strong  will  do  not  go  together,  and  that  every  means 
should  be  taken  in  such  patients  to  develop  the  power  of  the  will. 

It  should  be  stated,  however,  that  obstinacy  is  not  synonymous  with 
will  power,  but  may  coexist  with  real  feebleness  of  purpose  and  of 
sustained  effort.  The  mistake,  however,  should  not  be  made  that 
hysteric  symptoms,  whether  motor  or  mental,  are  in  themselves  imagin- 
ary; instead  of  that,  they  are  real,  as  shown  by  the  conditions  found  in 
the  larynx  in  hysteric  aphonia.     At  such  times,  when  the  laryngoscope 


HYSTERIA  539 

is  used,  the  vocal  chords  are  found  to  be  absolutely  paralyzed.  Of 
course,  the  patient  has  never  seen  her  vocal  chords,  and,  therefore,  can- 
not voluntarily  paralyze  them.  Hence,  the  paralysis  of  these  chords 
is  real  and  not  imaginary,  and  what  is  true  of  the  larynx  is  also  true 
of  a  leg  paralyzed  in  hysteria.  Likewise,  it  is  very  uimatural  to  infer 
that  the  varied  mental  phenomena  of  hysterics  are  imaginary.  A 
hysteric  woman  will  be  most  voluble  in  descriptions  of  her  sufferings, 
and  puzzle  an  inexperienced  physician  with  their  variety,  and,  accord- 
ing to  her  statement,  with  their  severity,  but  one  feature  of  this  con- 
dition is  that  new  pains,  aches,  or  disabilities  can  occur  by  simple 
suggestion.  Let  the  physician  gravely  state  that  she  has  omitted  to 
mention  some  disabihty  of  her  knee-joint,  and  forthwith  she  exclaims 
that  she  has  it. 

Motor  Phenomena. — A  woman,  after  a  quarrel  with  her  husband, 
had  her  jaw  locked  by  trismus.  Shortly  afterward  her  husband  entered, 
whereupon  her  trismus  immediately  relaxed,  and  she  began  to  have 
universal  contortions,  writhing  Hke  an  eel,  as  her  physician  described, 
and  tearing  her  clothes  to  tatters.  After  these  clonic  convulsions, 
which  lasted  an  hour,  she  apparently  became  comatose  from  exhaustion, 
in  which  state  she  continued  for  two  hours,  and  then  became  herself 
again  upon  passing  a  large  quantity  of  limpid  urine.  Jn  many  of 
these  cases  of  hysteric  convulsions  it  is  curious  that,  after  their  subsi- 
dence, the  patients  have  no  recollection  of  what  they  have  done.  In 
this  respect  hysteric  convulsions  resemble  those  of  epilepsy,  so  that  a 
special  division  has  been  made  by  some  neurologists  and  termed 
"hystero-epilepsy."  I  do  not  regard  these  cases  as  at  any  time  verging 
upon  true  epilepsy,  for  the  attacks  are  never  so  sudden  as  in  epilepsy, 
do  not  come  on  in  sleep,  do  not  cause  the  patient  to  fall,  or,  if  they  do, 
they  take  care  not  to  hurt  themselves  by  striking  surrounding  objects. 

Every  form  of  organic  mischief  in  brain  or  spinal  cord  can  be 
imitated  by  hysteria,  but  there  will  always  be  lacking  certain  features 
of  organic  paralyses  in  hysteric  affections  which  simulate  them.  Thus, 
in  hysteric  hemiplegia  the  face  escapes,  as  it  never  does  in  the  organic 
form.  Hysteric  hemiplegia  is  not  nearly  so  common  as  monoplegia. 
Of  the  monoplegias,  the  commonest  involve  one  leg.  This  may  come 
on  slowly  or  suddenly,  the  gait  being  very  characteristic,  for  the  patient 
does  not  swing  the  leg  as  he  does  in  hemiplegia,  but  has  a  foot-drop  in 
the  line  of  walking.  When  one  leg  alone  is  affected  the  symptoms 
are  often  preceded,  for  a  greater  or  less  length  of  time,  by  other  hys- 
teric manifestations.  Nearly  always  there  is  a  loss  of  sensation  in  the 
affected  limb,  which  may  even  exceed  the  motor  paralysis.     Hysteric 


S40 


CLINICAL  MEDICINE 


paraplegia  has  much  the  characteristics  of  monoplegia,  but  may  cause 
some  uncertainty  in  diagnosis,  owing  to  the  bladder  being  apparently 
involved.  There  is  always,  however,  one  important  sign  present,  that 
in  hysteric  paralyses  of  limbs  wasting  and  atrophy  never  occur,  nor 
does  coldness  of  the  limbs,  and  the  electric  responses  are  usually  nor- 
mal. 

Hysteric  Contractures. — These  curious  manifestations  may  occur 
an3rwhere  in  the  body,  from  the  jaw  downward,  and  a  remarkable  fea- 
ture about  them  is  that  they  sometimes  persist  for  months  or  even 
years,  and  then  show  their  hysteric  character  by  disappearing  without 
cause.  Of  these  contractures,  a  good  example  is  found  in  the  arm,  which 
is  flexed  at  the  elbow  and  wrist,  while  the  fingers  tightly  grasp  the 
thumb  in  the  palm  of  the  hand.  One  of  the  most  disconcerting  cases,  in 
my  experience,  was  when  I  was  invited  by  a  friend,  who  was  an  emi- 
nent gynecologist,  to  attend  an  operation  on  a  tumor  in  the  abdomen, 
which  he  had  diagnosed  as  an  ovarian  cyst.  When  the  patient  was 
anesthetized  the  tumor  vanished.  These  phantom  tumors  are  caused 
by  temporary  contractions  in  the  muscle  walls  of  the  abdomen,  but  they 
have  been  known  to  occur  in  the  pectoral  muscles. 

Contractures  in  one  or  in  both  legs  are  very  common,  and  may  per- 
sist for  months,  the  diagnosis  of  their  hysteric  nature  being  possible 
by  the  absence  of  wasting  in  the  contracted  part. 

As  a  part  of  their  spectacular  tendency  some  hysteric  patients  are 
prone  to  deceive,  so  as  to  excite  sympathy.  Thus,  some  of  them  have 
been  known  to  drink  urine  so  as  to  vomit  it.  Another  leading  charac- 
teristic of  these  patients  is  their  selfishness,  which  causes  them  in- 
variably to  shirk  their  ordinary  duties,  on  the  plea  of  their  being  so 
extraordinarily  affected.  A  truly  unselfish  hysteric  is  unknown.  The 
passion  for  display  leads  sometimes  to  attempts  at  self -mutilation.  I 
once  had  a  hysteric  woman  who  introduced  io6  needles  into  her  knee,. 
which  were  only  discovered  when  the  surgeon  proposed  to  amputate  the 
limb. 

Anesthesias. — Hysteric  anesthesias  may  be  strictly  localized  or 
very  general,  usually,  however,  developing  on  one  side  of  the  body. 
They  are  often  of  use  in  diagnosis,  because  they  do  not  occur  in  the 
skin  areas  involved  in  anesthesias  of  organic  origin.  When  extensive,, 
the  skin  feels  cool,  and  a  prick  with  a  pin  does  not  draw  blood. 

Hyperesthesias. — Corresponding  to  the  regular  cutaneous  anesthe- 
sias, there  are  patches  of  hypersensitiveness  on  the  skin,  pressure  on 
which  may  bring  on  a  regular  attack  of  hysteria.  These  are  specially 
frequent  when  pressure  is  made  in  the  region  of  the  ovary.     A  pain,. 


PARALYSIS   AGITANS  54 1 

however,  develops  in  the  course  of  the  sagittal  suture  of  the  cranium, 
and  is  called  the  clavus  hystericus.  It  usually  is  accompanied  by 
great  mental  excitement  and  screams  so  long  as  spectators  are  about. 

The  breathing  is  often  deranged  in  hysteric  attacks,  the  respiration 
being  very  gasping,  or  the  breath  held  until  the  face  becomes  cyanosed. 
I  was  once  called  in  consultation  by  two  physicians  to  see  a  patient 
who  had  not  left  her  bed  from  paralysis  for  eighteen  months,  but  the 
night  before  she  summoned  all  her  friends  to  see  her  die  of  suffocation. 
I  ordered  every  person,  including  the  physician,  to  go  out  of  the  room, 
and  then  went  up  and  pulled  her  out  of  her  bed  into  the  middle  of  the 
room,  then  left  her  standing  there  and  told  her  to  walk  back  to  the 
bed,  which  she  angrily  did.  I  then  told  her  that  she  could  walk  any- 
where, and  so  in  a  week  she  went  to  church. 

Hysteria  may  occur  at  any  age,  for  I  have  seen  hysteric  anesthesia 
in  a  child  of  only  ten  years  and  a  typical  hysteric  emotion  in  a  woman  of 
sixty-five.  In  children,  however,  it  is  often  due  to  simple  unitation, 
and  epidemics  of  hysteric  attacks  are  by  no  means  unknown  in  boarding 
schools.  A  medical  friend  of  mine  once  stopped  such  a  series  of  out- 
breaks by  pouring  a  bucket  of  cold  water  over  a  girl  m  the  presence  of 
the  school,  and  threatened  to  repeat  this  performance  on  the  next  girl 
who  became  hysteric. 

Treatment. — As  to  treatment,  the  first  indication  is  to  secure  a 
regular  and  healthy  action  of  the  bowels.  In  the  majority  of  these 
patients  the  bowels  are  obstinately  constipated,  and  disorders  of  diges- 
tion are  the  rule,  but  always  without  any  true  symptoms  of  inflamma- 
tory disturbance.  The  most  trustworthy  medicmal  remedies  are  of  a 
stimulant  kind,  such  as  asafetida,  valerian,  and  camphor.  A  pro- 
longed course  of  these  remedies,  combined  with  powdered  rhubarb, 
soda,  and  other  mtestinal  antiseptics,  is  advisable.  Usually  the  anti- 
spasmodics, as  they  are  called,  such  as  asafetida  and  valerian,  are 
employed  only  occasionally,  when,  to  do  good,  they  should  be  given 
systematically  daily  for  weeks  at  a  time. 

A  course  of  5  gr.  of  the  sulphocarbolate  of  soda,  with  i  gr.  of  camphor 

and  3  gr.  of  powdered  asafetida,  in  two  capsules,  may  be  given  three 

times  a  day  an  hour  after  meals,  to  be  followed,  after  two  weeks,  by 

a  prescription  of  a  dram  of  the  valerianate  of  zinc  and  10  gr.  of  powdered 

aloin,  made  up  into  twenty  silver-coated  pills,  one  to  be  taken  four 

times  a  day. 

PARALYSIS  AGITANS 

Paralysis  agitans,  or  shaking  palsy,  also  called  Parkinson's  disease, 
as  he  first  described  it  in  181 7,  is  an  affection  with  very  characteristic 


542  CLINICAL  MEDICINE 

sjonptoms,  consisting  of  coarse  tremors  at  the  rate  of  six  vibrations  a 
second.  It  affects  men  more  than  women,  very  rarely  before  thirty, 
and  most  commonly  after  forty,  years  of  age. 

Some  writers  speak  of  it  as  an  aggravation  of  ordinary  senile  tremor, 
but  this  is  a  mistake,  for  it  does  not  begin  as  such  tremors  do,  nor  do 
they  end  in  the  characteristic  general  muscular  rigidity  of  this  affection. 

The  only  common  antecedent  is  a  localized  trauma,  such  as  a  blow 
on  the  shoulder  or  a  wrench  of  the  hand,  from  which  the  disease  is 
slowly  propagated,  with  all  its  special  symptoms,  to  one  part  after 
another,  till  the  whole  muscular  system  becomes  involved,  with  the 
exception  of  the  muscles  which  move  the  eyeballs.  Every  affected 
muscle  then  behaves,  in  turn,  as  the  first  did,  never  changing  into  any 
other  muscular  affection;  all  of  which  goes  to  show  how  specific  the 
malady  is. 

Numerous  and  exciting  causes  of  the  disease  are  mentioned  by 
writers,  such  as  emotional  shocks,  fright,  worry,  or  anxiety  or  exposure 
to  cold,  overwork  and  hardship,  or  following  infections,  such  as 
grippe,  typhoid,  or  pneumonia.  These  can  only  be  ranked  as  con- 
tributory causes,  because  they  may  every  one  of  them  occur  without 
causing  paralysis  agitans,  which  fact  becomes  quite  plain  from  the 
following  recital  of  the  symptoms  of  the  disease. 

Symptoms. — The  symptoms  consist  of  rhythmic  contraction  of  the 
flexors  and  extensors,  never  violent  nor  spasmodic  in  character.  They 
can  be  arrested  at  the  beginning  for  a  brief  period  by  the  will,  but  then 
they  quickly  return,  and  are  just  as  evident  during  periods  of  rest. 
They  cease  during  sleep.  The  marked  pecuHarity  is  that  they  begin 
most  frequently  in  the  arms  or  hands,  one  being  affected  for  some 
months  before  the  other.  No  explanation  can  be  furnished  any  more 
than  for  the  rest  of  the  features  of  this  disease.  Rather  uncommonly 
the  beginning  is  in  the  legs.  When  it  begins  in  the  hands  the  index- 
finger  and  thumb  are  usually  affected  before  the  other  fingers,  when  the 
patient,  by  pressing  the  thumb  against  the  first  finger  to  stop  the 
tremor,  makes  the  pen-posture  of  the  hand  quite  characteristic  of 
the  disease.  Either  exercise  or  passive  movements  often  temporarily 
mitigate  the  tremor,  and  so  does  the  vibration  of  a  railway  train. 
One  of  the  first  effects  of  this  condition,  if  the  tremor  has  begun  in  the 
right  hand,  is  to  alter  the  hand-writing,  which  exercise  in  time  becomes 
impossible.  There  is  always  an  extension  of  the  tremor  from  the  part 
first  affected  to  other  parts,  until,  in  the  end,  all  the  extremities  are 
affected.  Usually  the  tremor  extends  from  an  arm  to  a  leg  of  the  same 
side,  but  sometimes  it  appears  in  the  other  arm  before  the  leg  is  affected. 


PARALYSIS    AGITANS  543 

Ordinarily,  one  or  two  years  elapse  before  an  extension  to  a  second 
limb  is  noticed.  Finally,  tremor  of  the  head  sets  in,  often  with  a  tremor 
of  the  jaw  or  of  the  lips  and  tongue. 

There  now  follows  the  second  marked  feature  of  the  disease,  namely, 
rigidity.  This  usually  appears  first  in  the  movement  of  the  head  and 
neck,  the  patient  turning  his  eyes  by  moving  the  body  with  the  head, 
as  he  finds  difficulty  in  independent  movements  of  the  head  and  neck. 
This  rigidity  soon  extends  from  the  neck  to  the  extremities,  and  finally  to 
every  muscle  of  the  body.  The  head  is  then  bent  forward,  the  arms 
usually  being  held  to  the  sides,  with  the  elbows  flexed,  the  wrists  ex- 
tended, and  the  first  phalanges  flexed.  Abduction  of  the  thighs  is 
hampered,  and,  in  walking,  the  knees  are  approximated,  while  the 
steps  are  short.  The  facial  muscles  also  become  stiff,  so  that  the  face 
has  no  expression  from  immobility  of  its  muscles.  Finally,  even  the 
vocal  chords  become  stiff.  In  some  the  speech  is  monotonous  or  very 
weak  and  feeble,  with  jerky  pronunciation,  and  occasionally  the  patient 
talks  only  in  whispers.  This  general  rigidity  hampers  all  movements, 
so  that  in  walking  the  patient  bends  forward  and  often  hurries  his 
steps  to  keep  from  falling,  so  that  he  frequently  catches  hold  of  an 
object  to  prevent  this.  In  short,  there  is  an  abohtion  of  the  instinctive 
movements  of  the  body  to  keep  it  in  the  erect  position. 

Meantime,  it  is  remarkable  that  the  muscles  do  not  waste  nor  show 
tendencies  to  fibrillary  twitching.  There  is  no  muscular  atrophy  nor 
any  changes  with  electric  currents.  The  deep  reflexes  are  usually 
normal  or  in  a  few  cases  exaggerated.  One  of  the  most  distressing 
accompaniments  of  the  rigidity  is  the  presence  of  an  aching  feeling 
all  over  the  body,  producing  a  constant  sense  of  restlessness,  so  that 
the  patients  think  that  they  will  obtain  relief  by  change  of  posture. 
This  aching  is  usually  dull,  and  does  not  often  amount  to  pain,  but  is 
frequently  accompanied  by  paresthesia,  such  as  tickling  or  tingling, 
numbness,  or  sensations  of  heat  and  of  cold,  either  in  the  shaking  limb 
or  all  over  the  whole  body.  The  most  common  sensation  is  a  burning 
feeling  in  the  skin,  which  may  feel  quite  hot  to  the  touch,  though  there 
is  no  fever.  There  is  never  any  anesthesia,  but  occasionally  consider- 
able sweating.  The  functions  of  the  bladder  and  rectum  are  not 
affected,  but,  with  restless  patients,  insomnia  is  often  troublesome. 
Though  authors  maintain  that  paralysis  agitans  is  never  a  fatal  dis- 
ease, my  own  experience  is  quite  different,  death  being  usually  pre- 
ceded by  symptoms  of  general  exhaustion. 

In  a  few  cases  the  development  of  rigidity  precedes  that  of  tremor. 
From  the  foregoing  account  of  the  symptoms  it  seems  plain  that  paral- 


544  CLINICAL  MEDICINE 

ysis  agitans  is  a  disease  sui  generis,  and  that  its  pathology  is  still  un- 
known. In  some  cases,  however,  complete  change  of  surroundings 
causes  remarkable  improvement  in  the  condition  of  the  patient. 

GASTRIC  AND  OTHER  NEUROSES 

There  is  a  great  contrast  between  the  organs  of  the  thorax  and 
those  of  the  abdomen  in  their  relations  to  general  vitality.  However 
immediately  necessary  to  Hfe  the  heart  and  the  lungs  may  be,  yet  even 
serious  organic  changes  in  them  may  exist  without  causing  much  anx- 
iety in  the  subjects.  A  patient  with  a  large  tuberculous  cavity  in  his 
lung  is  often  sanguine  about  his  recovery.  So,  when  medical  students 
are  frightened  by  palpitation  of  the  lieart,  it  is  fair  to  infer  that  they 
have  only  dyspepsia,  because  valvular  affections  of  the  heart  do  not 
commonly  cause  apprehension. 

Far  otherwise  is  it  when  anything  happens  below  the  diaphragm. 
The  one  word  which  then  describes  the  effect  is  "alarm."  Even  the 
simplest  fimctional  disorders  of  the  stomach  produce  depression  of 
the  spirits ;  but  still  more  profound  is  the  effect  of  a  lesion  involving  the 
stomach  wall,  for  the  smallest  hole  through  it  causes  immediate  col- 
lapse. So  far  as  danger  to  life  is  concerned,  a  surgeon  would  rather 
amputate  a  leg  than  make  a  small  clean  incision  in  the  perineum  for 
extracting  a  stone  from  the  bladder. 

The  reason  for  all  this  lies  in  the  relations  of  the  abdominal  nerves 
and  their  ganglia  to  Hfe  itself.  Purely  functional  derangements  in  the 
abdomen,  unaccompanied  by  any  discoverable  anatomic  changes,  will 
yet  occasion  a  greater  variety  of  distressing  symptoms  than  functional 
disorders  anywhere  else  in  the  body.  On  that  accoimt  no  disorders 
so  often  present  such  difficulties  in  diagnosis.  Hysteria,  for  example, 
can  imitate  everything,  including  death,  and  hysteria  has  its  origin, 
as  we  shall  see,  in  disturbance  of  the  abdominal  sympathetic. 

Gastralgia. — All  this  is  well  illustrated  in  that  neurosis  of  the 
stomach  called  gastralgia.  In  a  typical  case  the  patient  is  suddenly 
seized  with  severe  pains  in  the  epigastrium,  which  radiate  to  the  back 
round  the  lower  ribs.  The  attacks  are  definitely  paroxysmal,  and  may 
be  separated  by  long  intervals.  The  patient  describes  the  pains  as 
agonizing,  and  demands  immediate  relief,  while  the  physician  may  be 
well  perplexed  about  the  diagnosis,  and,  therefore,  as  to  what  he  should 
do.  Just  such  symptoms  accompany  gall-stone  coHc  when  this  occurs 
without  jaundice,  in  which  also  hyperacidity  may  be  associated  with 
gastric  atony,  or  similar  attacks  occur  in  connection  with  gastric  ulcer, 
and,  like  many  cases  of  gastralgia,  are  relieved  by  taking  some  food. 


GASTRIC   AND   OTHER   NEUROSES  545 

Another  trouble  must  be  borne  in  mind,  and  that  is,  the  intermittent 
gastric  crises  of  tabes  dorsahs.  All  these,  however,  have  other  and 
characteristic  symptoms  not  present  in  true  gastralgia,  and  upon  them 
a  differential  diagnosis  can  be  made. 

Gastralgia  occurs  chiefly,  though  not  exclusively,  in  women.  But 
in  both  sexes  other  manifestations  of  nervous  conditions  are  present, 
such  as  unnatural  excitabiUty,  both  physipal  and  mental.  Taking  of 
food  in  small  quantities  usually  gives  relief  for  a  time,  and  the  attacks 
supervene  ordinarily  when  the  stomach  is  empty.  Rumblings  of  gas 
in  the  stomach  are  frequent,  and  eructations  give  reHef.  Vomiting, 
however,  is  uncommon,  while  both  chills  and  vomiting  often  occur 
with  gall-stones. 

Other  gastric  neuroses  are  sudden  attacks  of  excessive  hunger, 
frequently  nocturnal,  to  which  the  term  "bulimia"  is  given.  This  is 
very  common  in  Graves'  disease.  It  may  occur  in  diabetes,  but  then 
it  is  not  so  paroxysmal.  The  same  may  be  said  of  abnormal  hunger 
in  epilepsy  or  even,  though  rarely,  in  cerebral  tumors. 

Dr.  T.  Clifford  Allbutt  ("System  of  Medicine,"  vol.  iii,  p.  405) 
speaks  of  enteralgia  as  the  most  terrible  of  all  neuralgias.  He  de- 
scribes it  as  occurring  oftenest  about  the  navel,  and  then  radiating  to 
the  spine,  often  involving  more  than  one  spinal  segment.  I  have  never 
seen  a  case  of  this  complaint,  but  as  one  of  his  patients  finally  escaped 
recurrence  of  the  attacks  when  she  developed  articular  gout,  I  suspect 
the  whole  trouble  was  gouty.  Ordinary  articular  gout  frequently 
sets  in  during  the  night,  with  excruciating  pains  in  the  joints,  and  I 
can  imagine  an  analogous  connection  of  this  complaint  with  true 
visceral  gout.  England,  whose  people  more  than  any  other  consume 
beers  and  ales,  is,  therefore,  the  home  of  gout,  and  thus  may  be  the 
country  of  enteralgia  also. 

But  the  term  "neuralgia"  is  so  often  loosely  used  that  it  should  be 
defined  here.  It  means  a  pain  located  in  a  nerve  which,  however,  is 
not  inflamed.  The  pain  of  inflammation  is  always  increased  on  press- 
ure and  by  movement  of  the  part,  but  gastralgia,  like  other  neuralgias, 
is  increased  by  neither  pressure  nor  movement.  The  patients  instead 
often  press  down  on  the  aching  part,  and  the  muscles  over  the  affected 
part  are  not  resistant  or  rigid,  as  they  always  are  in  ulcer  or  true  gas- 
tritis. The  term  "trigeminal  neuralgia"  is,  therefore,  a  true  neuritis, 
and  should  be  treated  accordingly.  The  same  may  be  said  of  brachial 
neuralgia. 

The  term  "neuralgia,"  therefore,  simply  means  an  aching  nerve  and 
not  an  inflamed  nerve.  Neither  are  the  severe  pains  which  accompany 
35 


546  CLINICAL   MEDICINE 

degeneration  of  nerve-tracts,  such  as  those  in  tabes,  properly  neuralgic, 
because  well-defined  organic  changes  accompany  the  pains.  Such 
changes  are  absent  in  a  true  neuralgia.  But  what  makes  the  nerve 
ache?  An  old  saying  is  perfectly  true,  that  neuralgia  is  a  cry  of  the 
nerve  for  better  blood.  It  is  a  blood  disorder,  and  not  a  nerve  dis- 
order, and  in  every  case  is  due  to  a  fimctional  blood-poison  whose  action 
presents  no  perceptible  anatomic  changes.  The  importance  of  this 
principle  is  great.  Thus,  there  is  no  more  pronounced  nervous  dis- 
ease than  melanchoHc  insanity.  But  the  brain  is  not  at  fault  in  this 
terrible  affliction.  The  most  careful  inspection  in  melanchoHa  fails 
to  show  the  least  change  from  a  normal  brain.  Melancholia  is,  there- 
fore, a  blood  disease,  and  I  have  had  much  more  success  in  treating  it 
as  such  than  by  using  any  agents  that  act  on  the  nervous  mechanism 
itself. 

These  facts  do  not  make  the  treatment  of  gastralgia  or  of  any 
neuralgia  a  simple  matter.  An  inflammation  we  can  treat  at  once,  but 
a  pronounced  neuralgia  means  that  we  must  treat  nearly  all  abdominal 
functions  together.  We  should  first  begin  with  all  the  disorders  of 
digestion,  for  the  alimentary  canal  is  our  blood-making  factory. 

Dyspepsia. — A  proportion  of  cases  of  nervous  dyspepsia  are  de- 
pendent upon  purely  mental  causes,  such  as  worry  or  too  continued 
routine  in  life,  when  a  vacation  or  change  of  scene  will  accomplish 
what  years  of  treatment  at  home  have  failed  to  do,  as  we  have  already 
mentioned  in  speaking  of  the  effect  of  change.  In  many  of  these  cases, 
especially  in  women,  the  appetite  has  long  been  absent,  so  that  they 
eat  very  Httle.  Weir  Mitchell's  treatment  of  rest  in  bed,  with  stated 
feeding,  will  frequently  accomplish  wonders.  Among  the  functional 
disorders  of  the  stomach  we  meet  with  cases  of  hyperacidity  or  hyper- 
chlorhydria.  This  can  be  determined  only  by  examining  the  contents 
of  the  stomach  after  a  meal.  And  in  them,  besides  the  other  general 
treatment  of  the  neurotic  condition,  alkalis,  either  in  the  form  of 
magnesia  or  bicarbonate  of  soda,  should  be  given  in  large  doses  at 
the  height  of  digestion  rather  than  on  an  empty  stomach.  In  such 
cases  also  uro tropin  frequently  gives  relief  taken  before  food,  beginning 
with  5  gr.  and  gradually  increased.  The  diet  should  be  mainly  albu- 
minous, while  alcohol  should  be  avoided.  Starchy  foods  should  be 
sparingly  allowed,  fats  being,  on  the  other  hand,  fairly  well  borne. 
Dyspepsia  associated  with  hyperacidity  calls  for  a  strictly  meat  diet, 
best  given  with  scraped  raw  meat  in  small  boluses  rolled  in  cracker 
crumbs.  As  much  as  3^  oz.  of  meat  may  thus  be  given,  spread,  if 
need  be,  between  two  thin  slices  of  bread  and  butter.     Purely  albu- 


NEURASTHENIA  547 

minous  food,  such  as  hard-boiled  eggs,  may  be  taken  when  the  attacks 
come  on,  while  alkalis  in  large  doses  are  beneficial. 

Cases  of  continued  supersecretion  are  usually  due  to  atony  and  dila- 
tation of  the  stomach;  the  same  treatment  as  that  just  outlined  may  be 
followed,  though  the  food  should  be  taken  in  smaller  quantities  and  at 
frequent  intervals.  It  is  in  these  cases  that  lavage  with  alkaline  solu- 
tions are  of  such  value.  In  deficient  acidity  bitter  tonics  are  valuable, 
taken  before  meals.  A  good  powder  for  this  is  lo  gr.  each  of  powdered 
columbo  and  subcarbonate  of  bismuth.  It  is  in  these  cases  also  that 
pepsin  is  of  value,  and  may  be  administered  in  2  teaspoonful  doses 
in  water  after  meals  of  Fairchild's  essence  of  pepsin,  acidulated  by  4 
drams  of  lactic  acid.  Continued  use  in  these  cases  of  arsenic,  in  from 
3  to  4  drops  of  Fowler's  solution,  is  often  beneficial. 

NEURASTHENIA 

This  term  means  Hterally  nervous  weakness;  medically,  however,  it 
means  loss  of  control.  Our  nervous  system  is  made  up  of  a  great 
hierarchy  of  nerve- centers,  with  the  lower  members  being  always 
subject  to  check  or  rule  by  those  above  them.  Thus,  as  we  have  al- 
ready remarked,  if  the  basal  ganglia  in  the  brain  of  a  frog  are  intact, 
stimulation  of  the  skin  will  not  cause  any  excitabiUty  of  a  spinal  nerve, 
but,  if  the  basal  ganglia  are  removed,  the  sKghtest  stimulation  will 
cause  the  muscles  of  the  forelimbs  and  hindlimbs  to  move  actively. 
One  of  the  greatest  functions  of  the  nervous  system  is  called  inhibition, 
by  which  is  meant  not  that  any  nerve  function  is  abolished,  but  that  it 
is  checked  and  controlled  by  higher  nerve-centers.  Thus,  the  heart 
is  supplied  by  two  opposite  classes  of  nerves,  first,  the  accelerators 
coming  from  the  spinal  cord,  which  make  the  heart  beat  more  rapidly, 
and  the  cardiac  inhibitory  nerves,  which  come  through  the  vagi,  making 
it  beat  more  slowly  as  well  as  powerfully.  If  a  man  should  suddenly 
hear  a  serious  piece  of  news  without  his  pulse  being  affected  thereby 
we  would  regard  him  as  a  strong  man,  while  another,  whose  pulse  runs 
up  30  or  40  beats  when  he  sees  that  a  boy  is  about  to  snowball  him,  we 
would  rate  as  a  weak  man.  Neurasthenics,  whether  men  or  women,  are 
persons  deficient  in  self-inhibition  or  control. 

Some  of  the  worst  cases  of  neurasthenia  that  I  have  seen  were  in 
men  who  broke  down  during  a  business  strain.  Previous  to  that  they 
were  healthy  men,  but  afterward  they  were  fearful,  emotional,  and 
dreaded  every  kind  of  responsibility.  These  cases  were  particularly 
common  after  general  financial  crises  or  panics,  and  are  just  as  explic- 
able as  cases  of  men  fainting  from  muscular  overexertion. 


548  CLINICAL  MEDICINE 

Loss  or  weakness  of  self-control  may,  however,  be  congenital,  and 
illustrates  the  old  joke  that  one  should  be  careful  in  the  choice  of  his 
parents.  In  all  such  cases  the  judicious  physician  should  know  what 
to  do,  namely,  begin  to  cultivate  self-control.  This  can  be  developed 
by  the  proper  exercise  of  the  faculties,  just  as  the  muscles  of  the  calf 
of  the  leg  can,  by  proper  dancing,  be  very  different  from  the  same 
muscles  before.  This  is  one  of  the  most  encouraging  facts  about 
treatment  of  all  cases  of  so-called  neurasthenia. 

One  of  the  conunonest  causes  of  neurasthenia  is  from  sexual  abuse 
about  the  age  of  puberty,  of  which  masturbation  is  the  most  frequent 
cause,  and  which  is  by  no  means  limited  to  the  male  sex.  I  have 
known  of  nurses  teaching  this  practice  to  boys  only  three  years  old, 
but  in  after  years  it  is  so  thoughtlessly  indulged  in  that  parents,  and 
particularly  fathers,  are  truly  reprehensible  for  not  informing  their 
sons  of  what  a  dangerous  and  ruinous  practice  it  is.  After  masturba- 
tion has  been  indulged  in  for  some  time,  even  if  it  is  broken  off,  it 
may  leave  a  permanent  weakness  of  the  sexual  organs,  causing  after- 
ward prolonged  nocturnal  emissions  and  spermatorrhea  to  occur  even 
in  the  daytime.  No  such  wretched  neurasthenics  are  to  be  found  as 
these,  a  prey  to  all  quacks  and  charlatans,  who  make  them  actually 
hypochondriac  in  their  fears  of  approaching  impotence  or  insanity. 
One  effect,  I  have  found,  is  an  irritabihty  of  the  muscles  in  the  peri- 
neum, particularly  after  long  sitting.  Students  are  thus  prone  to  have 
sexual  ideas  enter  their  minds  while  at  their  studies.  I  have  found 
benefit  from  a  pad  tightly  pressed  against  the  perineum  by  means  of 
an  apparatus  consisting  of  a.  broad  band  around  the  waist,  with  a  pair 
of  straps  brought  up  from  the  perineal  pad  and  fastened  to  the  ab- 
dominal belt  by  buckles.  Cold-water  douching  of  the  privates  night 
and  morning  is  beneficial. 

Neurasthenics  are  very  common  among  women,  with  whom  loss 
of  control  of  the  emotions  is  natural,  and  has  a  great  deal  to  do  with  the 
genesis  of  hysteria  and  all  its  multiform  manifestations. 

Treatment. — We  have  already  alluded  to  the  great  effects  of  change, 
as  such,  not  only  in  the  treatment  of  nervous,  but  actual  nutritional, 
diseases.  In  many  cases  of  aggravated  neurasthenic  states  the  pa- 
tients should  have  everything  about  them  changed.  They  should  be 
removed  from  their  families,  and  in  the  regulation  of  their  diet  and 
ordinary  hygiene  be  placed  in  different  surroundings  from  those  to 
which  they  are  accustomed.  This  is  the  secret  of  the  justly  celebrated 
Weir  Mitchell  treatment,  but,  after  all,  the  fundamental  principle 
here  is  to  develop  self-control  of  both  bodily  and  mental  habits. 


MIGRAINE 


549 


In  many  cases  of  neurasthenia  preparations  of  the  glycerophos- 
phates of  lime  and  of  soda  are  of  service,  of  which  the  following  formula 
might  be  tried: 

Wine  Glycerophosphates  {Calcium  and  Sodium) 

I^.     Calcium  glycerophosphate gr.  Ixiv; 

Sodium  glycerophosphate gr.  ccxxiv; 

Vin.  Malaga ad.  Oj; 

Flavor.  .■ q.  s.         .— M. 

Sig. — Dose,  2"  oz. 

MIGRAINE 

This  is  pre-eminently  a  class  disease,  which  fact  goes  far  to  ex- 
plain both  its  nature  and  its  etiology.  Thus,  whole  classes  of  persons 
may  not  suffer  from  migraine  at  any  time  in  their  lives,  such  as  sailors, 
farmers,  and  mechanics  who  pursue  their  avocations  in  the  open  air. 
On  the  other  hand,  students,  scholars,  housewives,  and  needlewomen 
are  among  its  worst  victims.  Many  eminent  men  have  fully  described 
the  symptoms  of  migraine  as  they  occurred  in  their  own  persons,  such 
as  Sir  John  Herschel,  Wheatstone,  and  Walliston.  The  explanation 
of  this  fact  is  that  migraine  does  not  attack  those  who  have  an  active 
portal  circulation,  while  sedentary  persons  are  quite  prone  to  it,  the 
reason  being  that  the  liver. contains  at  all  times  one-quarter  of  the  mass 
of  the  blood,  but  this  blood  is  prone  to  relatively  slow  movement,  be- 
cause the  whole  portal  circulation  is  a  department  intercalated  on. the 
venous  and  not  on  the  arterial  current,  and  hence  requiring  the  adju- 
vant action  of  the  diaphragm  in  respiration,  supplemented  by  the  con- 
traction of  the  abdominal  muscles  to  maintain  its  activity.  Being  an 
intermittent  affection,  it  cannot  properly  be  called  a  neurosis,  since  it  is 
virtually  a  toxemia  dependent  upon  a  special  poison  circulating  in  the 
brain.  By  analogy  to  other  selective  nerve  poisons  its  amount  may 
be  relatively  small,  accumulating  slowly  in  the  blood  until  it  explodes, 
as  it  were,  in  its  characteristic  onset.  We  have  spoken  of  this  in  dis- 
cussing the  subject  of  functional  nervous  disorders,  and  may,  there- 
fore, proceed  at  once  to  describe  its  symptoms,  just  as  we  would  the 
S3miptoms  of  a  nerve-poisoning  like  morphin. 

Symptoms. — The  patient  usually  wakes  up  in  the  morning  with  a 
general  sense  of  depression,  which  he  well  knows  is  a  precursor  of  the 
onset  of  his  old  enemy.  He  has  no  appetite,  and,  in  fact,  during  the 
acme  of  his  attack  the  movements  of  the  stomach  are  in  abeyance. 
Soon  the  headache  begins,  usually  on  one  side  of  the  head,  and  hence 
the  common  name  hemicrania.  In  different  patients  the  onset  is 
marked  by  various  ocular  disturbances,  the  commonest  being  scotoma. 


55©  ,  CLINICAL   MEDICINE 

or  specks  floating  before  the  eyes.  These  may  be  dark,  but  often  of 
brighter  colors,  persisting  for  an  hour  or  more.  Occasionally,  illusions 
of  geometric  figures  appear,  to  which  the  term  "teicopsia"  has  been 
given,  which  means  like  the  lines  of  a  fortification;  the  headache 
increases  in  severity  as  the  hours  go  on,  while  the  patient  becomes  fully 
prostrated  by  it  and  is  obliged  to  He  down.  At  this  time  it  is  not  un- 
common for  sensations  to  radiate  to  different  parts  of  the  body,  notably 
the  arm.  In  time  the  wretched  nausea  develops,  till  it  terminates  in 
active  vomiting,  whence  the  term  "sick  headache."  Usually,  the 
vomiting  relieves  the  patient  of  the  headache,  but  sometimes  the  nausea 
persists  for  twenty-four  hours.  Although  the  attacks  of  migraine 
usually  subside  in  one  day,  yet,  where  they  frequently  occur,  the  sense 
of  general  nervous  prostration  may  last  for  more  than  twenty-four 
hours. 

The  attacks  of  migraine  may  recur  only  once  a  month,  and  in  women 
particularly  about  the  time  of  their  menses,  but  in  severe  cases  they 
may  recur  so  often  as  to  render  Hfe  a  burden.  It  is  no  contradiction 
to  our  previous  contentions  about  this  disease,  that  it  is  so  often  hered- 
itary and  very  commonly  a  family  complaint,  because  there  is  no  such 
hereditary  element  in  us  as  disorders  of  digestion.  One  other  feature 
about  migraine  is  that  the  patients  outgrow  it,  as  it  is  uncommon  for 
it  to  continue  to  old  age. 

Treatment. — Being  chiefly  a  digestive  trouble,  prophylaxis  takes 
the  leading  part  in  the  management  of  these  cases,  for  whatever  pro- 
motes digestion,  by  so  much  lessens  the  tendency  to  attacks. 

First,  therefore,  as  to  prophylaxis.  All  severe  cases,  without  ex- 
ception, are  chronic  dyspeptics,  and  of  this  one  of  the  commonest 
symptoms  is  chronic  constipation.  A  mercurial  laxative,  such  as  a 
5-gr.  blue  pill  at  night,  with  a  saline  in  the  morning  to  secure  its  action, 
is  a  weekly  prescription  of  mine  which  I  strongly  insist  upon  in  every 
case,  to  be  kept  up  for  months.  I  am  sure  that  we  do  not  pos- 
sess a  more  certain  intestinal  antiseptic  than  a  mercurial  cathartic, 
and  I  never  feel  satisfied  when  a  patient  for  any  reason  declines  to 
persevere  in  its  employment.  As  a  further  systematic  measure  for  this 
purpose  I  prescribe  from  i  to  2  drams  of  the  sulphate  of  soda,  with  10 
gr.  of  sodium  saHcylate  in  a  tumblerful  of  hot  water,  to  be  sipped  down 
every  morning  on  rising.  With  some,  however,  the  sodium  phosphate 
is  preferred,  though  I  do  not  think  it  is  as  effective  as  the  sulphate. 
Then,  one-half  hour  before  each  meal,  a  pill  is  prescribed  of  2V  gr.  of 
bicarbonate  of  potash,  with  3  gr.  of  bismuth  subcarbonate.  Half  an 
hour  after  meals  and  at  night  full  doses  of  intestinal  antiseptics,  in  the 


MIGRAINE  551 

form  of  10  gr.  of  phenol  bismuth  or  naphthol  bismuth,  with  10  gr.  of 
ammonium  benzoate  or  sodium  benzoate,  are  given  in  two  capsules. 

While  the  benzoates  are  among  our  best  intestinal  antiseptics,  yet 
our  prescriptions  of  that  nature  ought  to  vary  in  different  cases  or  at 
different  times  in  the  same  case. 

Thus,  not  uncommonly,  the  signs  of  intestinal  derangement  include 
diarrhea  instead  of  constipation,  and  a  brief  recital  from  a  case  in  my 
notes  illustrates  both  how  our  prescriptions  may  be  varied,  and  how 
extensively  distributed  may  be  the  toxic  nervous  symptoms  of  a  bad 
case  of  migraine: 

Mrs.  C,  aged  thirty-five  years,  came  in  June,  1899,  for  early  morn- 
ing diarrhea  of  four  years'  standing.  She  was  frail  looking,  anemic, 
and  emaciated.  Has  a  great  deal  of  nausea,  and  fears  going  about 
alone  on  account  of  "spells,"  when  her  jaw  drops  and  she  becomes  im- 
conscious,  often  for  twenty  minutes  or  half  an  hour,  without  any  twitch- 
ing, and  when  she  recovers  she  feels  as  if  her  whole  body  had  lost  sen- 
sation, except  the  joints,  which  all  seem  to  ache  together.  At  other 
times  she  has  strange  feeUngs  come  on,  with  a  tight  sensation  in  the 
jaw,  which  drops,  and  she  has  then  to  sit  down  at  once.  She  has 
cramps  in  the  left  muscles  of  the  neck,  in  the  right  arm,  and  the  left 
leg,  with  much  nocturnal  aching  in  all  the  extremities.  With  every  one 
of  these  attacks  she  has  flashes  of  rainbow  colors,  till  she  becomes  quite 
blind;  at  other  times  she  has  for  hours  a  scotoma  before  the  right  eye  and 
and  a  distressing  dizziness.  Her  attacks  of  unconsciousness  come  on 
about  every  three  weeks,  but  the  nausea  and  headaches  occur  between 
times  so  often  that  she  rarely  passes  a  well  day.  She  was  ordered  to 
abstain  altogether  from  red  meats,  to  take  a  blue  pill  twice  a  week,  a 
21)  gr.  pill  of  kal.  bichromat.  with  bismuth  before  meals,  with  2  drams 
of  sodium  phosphate  and  10  gr.  of  sodium  saHcylate  in  hot  water  on  ris- 
ing, and  an  hour  after  meals  10  gr.  each  of  phenol  bismuth  and  sodium 
benzoate.  In  a  few  weeks  she  wrote  that  the  last-named  capsules  made 
her  nauseated.     A  prescription  of 

I^.     Salol 3ij; 

Bismuth  subgallate 5  j- — M. 

Ft.  pulv.  xxiv. 

one-half  hour  before  meals  and  at  night  was  substituted,  with  a  dessert- 
spoonful of  pancreatic  emulsion  half  an  hour  after  meals  for  her 
diarrhea. 

The  note  on  August  23d  was  that  she  was  improved  in  all  respects, 
with  subsidence  of  all  her  nervous  symptoms.     Had  only  one  attack 


552  CLINICAL  MEDICINE 

of  feeling  nervous  since  last  report,  and  has  gained  in  weight  and  in 
color.  The  last  note  is  February  27,  1900:  Looks  very  well,  has  no 
headaches  nor  any  of  her  old  symptoms,  but  she  Ukes  to  resort  fre- 
quently to  a  prescription  of  October  15th,  which  was 

I^.     Salicin 3ij; 

Ac.  benzoic! 3 ss; 

Bismuth  subcarb 3 vss. — M. 

Ft.  capsul.  xlviii. 
Sig. — Two  three  times  a  day. 

Now,  this  case  might  easily  have  been  mistaken  for  epilepsy,  but 
the  accompanying  symptoms  were  those  of  a  migranous  toxemia,  and 
she  recovered  without  taking  any  bromid.  The  blue  pill,  instead  of 
increasing  her  diarrhea,  seemed  to  check  it,  and  she  always  felt  better 
in  her  general  state  after  it. 

One  aggravated  patient  referred  to  me  from  an  inland  city  found, 
during  last  summer,  her  attacks  much  diminished,  both  in  frequency 
and  severity  (they  usually  prostrated  her  for  three  days),  and  she 
gained  15  pounds  in  weight,  but  this  September  she  had  two  sharp 
attacks.  I  changed  from  the  phenol  bismuth  and  benzoate  to  Dr.  M. 
Allen  Starr's  prescription  of — 

I^.     Sodium  sulphocarbol gr.  v; 

Cal.  permangan gr.  j; 

Betanaphthol gr.  j. — M. 

Sig. — One  after  meals  and  at  night, 

the  capsules  being  shellac  covered  to  prevent  their  solution  in  the 
stomach.     As  she  suffers  from  chronic  constipation,  she  took — 

I^.     Sodium  sulphate 3j; 

Sodium  phosphate §  ii j ; 

Sodium  salicylate 3ij- — M. 

Ft.  pulv.  xii. 
Sig. — One  in  a  tumblerful  of  water  as  hot  as  can  be  sipped  on  rising. 

She  took,  besides,  15  gr.  of  the  glycerophosphate  of  soda  after  meals. 
I  have  just  received  word  from  her  that  she  feels  much  improved, 
and  she  still  particularly  praises  the  effect  of  the  blue  pill. 

Prophylaxis  is  the  main  indication  in  the  treatment  of  this  com- 
plaint, but  for  the  attacks  themselves,  when  severe,  the  fluidextract 
of  ergot,  given  in  dram  doses  with  a  dram  of  elixir  cinchona  in  water,  by 
stomach  or  by  rectum,  is  the  most  certain  agent,  in  my  experience,  to 
cut  the  attack  short.    The  patient  should  lie  perfectly  still  after  taking 


RAYNAUD  S   DISEASE  553 

it  till  all  pain  passes  off,  and  in  some  cases  the  dose  may  be  repeated 
after  two  or  three  hours. 

In  those  who  cannot  take  the  ergot  without  vomiting  I  rely  on  10 
gr.  of  lactophenin,  with  2  gr.  of  caffein  citrate,  repeated  every  two 
hours  until  rehef  occurs,  or  15  gr.  of  antipyrin,  always  taken  with  a 
teaspoonful  of  aromatic  spirits  of  ammonia. 

Diet  is  a  matter  of  great  importance,  because  I  believe  that  in  every 
severe  case  the  red  meats  should  be  abstained  from  altogether,  or,  at 
least,  never  taken  at  night.  In  other  respects  the  digestive  abilities 
and  inabihties  of  each  patient  must  be  individually  studied,  as  all  ex- 
perienced practitioners  well  know.  Whatever  is  indigestible  for  any 
person  is  by  that  person  to  be  avoided,  but  I  find  no  general  rule  for 
this  purpose  except  one,  and  that  is,  that  if  any  article,  either  of  food 
or  of  drink,  is  tasted  again  in  an  eructation  from  the  stomach,  that  it 
does  not  want  any  more  of  that  stuff,  and  that  as  a  finality. 

All  nervous  functional  diseases  have  their  exciting  causes  as  well  as 
their  permanent  causes.  The  exciting  causes  should  never  be  con- 
founded with  the  permanent  causes,  as  they  often  are,  as  if  all  that  we 
have  to  do  is  to  prevent  them  and  then  the  disease  will  cease.  The 
commonest  exciting  cause  of  migraine  is  overtaxation  of  the  nervous 
system,  whether  by  thinking  or  by  feeling,  and  hkewise  by  undue  exer- 
tion of  the  voluntary  muscles.  On  this  account  migraine  belongs  to  the 
worrying  and  restless  periods  of  Hfe,  and  then  decUnes  with  the  greater 
repose  of  old  age.  I  have  been  struck  in  cases  of  persistence  of  mi- 
graine in  elderly  persons  that  it  seems  always  connected  with  con- 
tinuance of  causes  of  mental  anxiety  and  depression.  It  is  in  them  that 
we  have  to  fear  the  development  of  melancholia,  and  against  that  dread 
malady,  in  turn,  I  know  of  no  better  prophylactic  than  the  measures  for 
intestinal  antisepsis  which  have  been  outlined  for  the  treatment  of 
migraine. 

RAYNAUD'S  DISEASE 

This  appears  to  be  a  purely  vasomotor  disorder,  characterized  by 
a  local  spasmodic  contraction  of  the  arterioles.  It  may  be  relatively 
a  trivial  disorder,  and,  in  my  experience,  has  occurred  mostly  in  hys- 
teric patients,  who  complain  of  two  or  three  fingers  of  the  hand 
looking  and  feeling  dead.  In  time,  however,  usually  in  a  few 
hours,  a  return  to  the  opposite  condition  occurs,  in  which  the  fingers 
become  both  red  and  swollen.  But  Raynaud's  disease  may  be  a 
serious  and  even  fatal  complaint.  Some  of  the  worst  cases  are  reported 
in  children,  when  the  local  vasomotor  spasm  persists  and  shuts  off  the 
arterial  circulation  so  long  that  actual  gangrene  takes  place,  preceded 


554  CLINICAL   MEDICINE 

in  many  cases  by  severe  pains  in  the  part.  These  cases,  however,  are 
quite  rare,  and  their  etiology  is  obscure.  Many  cases  occur  only  in 
winter,  following  exposure  to  cold.  It  is  in  these  patients  that  hemo- 
globinuria is  apt  to  occur,  as  we  have  already  explained  in  our  remarks 
on  that  affection. 

Treatment. — Ra3maud's  disease,  when  once  estabHshed,  may  con- 
tinue for  years  in  its  recurrence.  During  the  attacks  I  would  recom- 
mend the  emplo)nnent  of  nitroglycerin  according  to  this  prescription — 
nitroglycerin,  |  gr. ;  water,  6  oz.;  dose,  from  i  to  2  teaspoonfuls  every 
hour.  When  the  attacks  occur  in  the  upper  or  lower  extremities,  Gush- 
ing recommends  the  emplo3nnent  of  a  tourniquet,  appHed  so  as  to  shut 
off  the  arterial  circulation  for  a  few  minutes,  and  then  removing  the 
pressure,  when  an  excess  of  arterial  blood  will  follow.  These  measures 
should  be  repeated  at  least  once  in  two  hours,  until  the  circulation 
returns  to  normal. 

We  may  allude  here,  in  this  connection,  to  the  not  uncommon 
affection  popularly  known  as  chilblains,  occurring  usually  as  an  ery- 
thematous condition  of  the  skin  about  the  feet  and  ankles;  the  heels 
are  particularly  apt  to  be  involved,  and  lead  to  intolerable  itching  and 
burning  of  the  parts.  Being  produced  by  cold,  they  are  best  treated 
by  the  application  of  hot  lime-water  liniment,  to  which  oil  of  cinnamon, 
in  the  proportion  of  i  dram  to  ^  pint  of  the  liniment,  should  be  added. 

ERYTHROMELALGIA 

This  rare  affection,  first  described  by  Dr.  Weir  Mitchell,  I  have 
seen  only  once,  in  the  person  of  an  admiral  of  the  American  Navy. 
Its  symptoms  are  a  redness  of  the  skin,  usually  of  the  feet,  accompanied 
by  severe  general  pains  in  the  affected  limb,  which,  however,  differs 
from  true  neuritis  in  not  being  aggravated  by  pressure. 

As  a  rule,  the  pams  are  mitigated  by  elevation  of  the  limbs,  and  are 
aggravated  by  long  standing  or  walking.  Most  cases,  but  not  all, 
improve  in  winter  and  are  worse  in  summer.  Although  one  would 
suppose  that  all  the  signs  of  neuritis  would  be  found,  the  only  common 
alteration  has  been  a  generaHzed  endarteritis  in  the  affected  parts. 

I  found,  in  the  above-mentioned  patient,  the  greatest  relief  was 
afforded  by  the  coal-tar  preparations  of  acetanilid  and  phenacetin. 


CHAPTER  XVII 
ORGANIC  NERVOUS  DISEASES 

LATERAL  SCLEROSIS 

The  most  satisfactory  account  of  this  affection  is  by  Erb,  who  fully 
described  it  in  1875. 

Lateral  sclerosis  is  very  probably  always  a  secondary  degeneration 
in  the  spinal  cord  proceeding  from  a  primary  focus.  The  lesions  that 
initiate  this  complaint  may  be  in  some  cases  demonstrated  in  the 
motor  region  of  the  brain  cortex  itself,  and  then  be  due  to  such  diverse 
causes  as  brain  tumor,  abscess,  or  thrombosis,  causing  injuries,  fol- 
lowed by  demonstrable  tracts  of  degeneration,  both  in  the  brain  and 
in  the  spinal  cord.  Organic  lesions  anywhere  in  the  brain  in  the  course 
of  pyramidal  tracts  in  the  cord  will  occasion  this  complaint.  It  is, 
therefore,  not  a  disease,  but  a  symptom  following  very  diverse  injuries. 

Symptoms. — The  chief  symptoms  are  at  first  referred  to  the  legs, 
often  involving  only  one,  but  generally  both  legs,  and  consist  at 
the  beginning  of  great  stiffness  in  movements  of  the  muscles,  making 
walking  very  slow  and  difficult.  Tremors  and  muscular  cramps  are 
common.  The  knee  reflex  is  much  exaggerated.  These  conditions 
are  plainly  illustrated  in  the  gait,  which  is  shuffling.  The  patient  can- 
not raise  the  toes,  while  the  ankle  clonus  is  increased,  and  the  knees 
have  a  tendency  to  overlap,  with  great  difficulty  in  abduction.  Much 
fatigue  i?  felt  on  walking.  The  whole  leg  becomes  as  stiff  as  if  it  were 
bound  in  a  splint,  and  both  knee  and  ankle  movements  are  abolished. 
In  time  the  stiffness  of  the  legs  leads  to  very  serious  contractures,  so 
that  the  heels  are  pressed  into  the  buttocks.  Passive  extension  of  the 
legs  becomes  impossible,  from  the  resisting  muscles  feeling  like  hard 
cords.  Ultimately,  the  tonic  contraction  of  the  muscles  causes  them 
to  waste  away,  for  nothing  shuts  off  the  circulation  of  the  muscles  like 
persistent  cramp.  The  muscles  of  the  hip,  however,  do  not  waste  so 
constantly  as  those  of  the  rest  of  the  leg.  There  is  no  disturbance  of 
the  bladder  or  rectum  and  no  sensory  symptoms,  except  those  produced 
by  the  cramps. 

In  the  majority  of  cases  the  upper  extremities  are  not  involved, 
but  when  they  are,  the  disease  follows  much  the  same  course,  beginning 
with  the  extensors  of  the  fingers  and  wrists,  conjoined  with  tremors. 

555 


556  CLINICAL  MEDICINE 

That  it  may  be  impossible  to  discover  a  primary  origin  of  this  com- 
plaint obHges  us  to  admit  that  there  are  cases  of  this  disease  beginning 
without  any  demonstrable  lesions  to  which  the  affection  is  secondary. 
All  authorities  agree  that  there  are  cases  apparently  of  true  primary 
lateral  sclerosis,  but  that  should  not  lead  us  to  omit  a  careful  search 
in  every  case  for  some  lesions  to  which  the  disease  is  secondary.  Thus, 
I  have  found  that  cases  with  all  the  symptoms  of  this  complaint  could 
be  ascribed  to  chronic  pachymeningitis,  and  their  contractures  success- 
fully treated,  as  hereafter  will  be  detailed. 

In  all  cases  the  disease  is  very  chronic,  and  may  at  any  time  become 
stationary. 

Treatment. — The  treatment  may  be  palliative,  and  consist,  me- 
dicinally, of  full  doses  of  antipyrin,  but,  still  better,  of  phenacetin; 
chloral  and  bromids  may  also  be  used.  But  for  the  painful  cramps  and 
startings  of  the  limbs  there  is  nothing  so  effective  as  the  warm-water 
douche,  which  should  always  be  practised  for  twenty  minutes  to  half 
an  hour  before  retiring. 

DISSEMINATED  SCLEROSIS 

Disseminated  or  insular  sclerosis  is  a  very  interesting  organic  dis- 
ease of  the  nervous  system  because  of  the  Hght  which  it  throws  on  the 
physiology  of  an  important  element  in  the  structure  of  the  nerves  of 
the  cerebrospinal  axis.  The  first  step  in  the  development  of  these 
nerves  is  the  production  of  the  axone,  subsequently  surrounded  by  a 
structure  called  the  medullary  sheath  of  Schwann.  This  sheath  of 
Schwann  contains  an  oily  material  which  is  wholly  different  in  its  ori- 
gin and  composition  from  those  of  the  axone. 

The  sheath  of  Schwann  is  made  up  of  tubes  joined  end  to  end,  with 
a  constriction  at  definite  intervals,  called  the  nodes  of  Ranvier.  These 
constrictions  in  no  way  interrupt  the  course  of  the  axone,  but,  when 
completed,  the  nerve  is  called  meduUated,  and,  on  account  of  the  com- 
position of  the  oily  substance,  gives  a  white  color  to  the  nerves,  which 
is  absent  in  non-medullated  nerves,  such  as  those  of  the  sympathetic 
system.  There  can  be  little  doubt  that  the  medullary  sheath  has  for 
its  purpose  to  insulate  the  axones  from  each  other,  analogous  to,  but  by 
no  means  identical  with,  the  insulation  of  an  electric  wire.  The  office 
of  the  myelin  sheath  is  simply  to  prevent  the  nerve  currents  of  adjacent 
axones  from  becoming  confusedly  mixed  with  each  other.  At  no  time, 
however,  should  a  nerve  current  be  confounded  with  an  electric  current, 
for,  whereas  a  motor  impulse  in  a  nerve  has  been  measured  to  traverse 
the  nerve  at  the  rate  of  about  140  feet  per  second,  an  electric  current 


DISSEMINATED   SCLEROSIS  557 

can  traverse  a  copper  wire  at  the  rate  of  188,000  miles  a  second.  But 
that  the  myelin  sheath  does  answer  a  property  of  insulation  analogous 
to  an  electric  insulation  is  shown  by  this  curious  disease,  disseminated 
sclerosis,  for  in  this  complaint  all  the  axones  appear  as  normal  as  ever, 
but  the  myelin  substance  has  wholly  disappeared.  What  causes  this 
disappearance  of  myelin  is  unknown;  the  most  probable  explanation 
is  that  it  is  due  to  an  unidentified  toxin. 

The  clinical  accompaniments,  however,  of  disseminated  sclerosis 
are  just  what  we  would  imagine  a  loss  of  insulation  of  nerves  be- 
tween each  other  would  produce.  All  the  muscles  of  the  body  seem 
then  to  work  independently,  the  gait  becomes  staggering,  as  if  the  man 
were  drunk,  and  even  the  movements  of  the  vocal  chords  become  ir- 
regular, so  that  the  voice  changes  to  what  is  called  "scanning,"  with  a 
tendency  to  clip  the  sentence.  Meantime,  the  movements  of  the  lips 
and  the  muscles  about  the  mouth  become  quite  irregular,  not  unlike 
the  efforts  of  speaking  by  persons  in  the  early  stages  of  paresis. 
The  muscles  that  move  the  eyeballs  also  become  affected,  produc- 
ing very  pronounced  nystagmus,  more  pronounced  than  in  any  other 
affection. 

One  of  the  clinical  accompaniments  of  disseminated  sclerosis  is 
that  of  decided  remissions,  which  may  last  for  several  months,  inducing 
a  deceptive  promise  of  cure.  The  disease,  however,  is  sure  to  return, 
and  generally  to  involve  parts  which  have  before  escaped. 

As  might  be  expected,  the  anatomic  findings  are  almost  universally 
limited  to  the  white  matter  of  the  brain  and  spinal  cord,  and  consist 
of  plaques  of  irregular  shapes  and  sizes.  The  sclerotic  patches  vary 
from  a  millimeter  to  several  centimeters  in  diameter,  and  are  of  irregu- 
lar shape.  In  a  fresh  state  the  patches  are  pinkish-gray  and  more 
translucent  than  normal  brain  tissue.  Some  have  a  gelatinous  ap- 
pearance. They  replace  the  brain  tissue  without  increasing  its  volimie, 
hence  are  not  like  small  tumors.  But  the  chief  feature  is  that,  as 
the  axones  are  not  involved,  no  secondary  degenerations  occur,  either 
leading  from  or  to  these  patches.  The  lesions  of  disseminated  sclerosis, 
therefore,  differ  altogether  from  any  other  sclerotic  degenerations  in 
nervous  tracts. 

Symptoms. — The  clinical  course  of  disseminated  sclerosis  is  so  va- 
ried in  its  accompanying  symptoms  that  Buzzard  is  quite  right  in 
saying  that  no  typical  picture  of  multiple  sclerosis  can  be  drawn. 

The  patient  has  some  numbness  and  weakness  in  the  legs,  which 
slowly  increases,  until  he  has  a  spastic,  ataxic,  or  even  cerebellar  gait, 
and  stiffness  and  paralysis  in  the  legs,  with  increased   knee-jerks, 


5S8  CLINICAL  MEDICINE 

ankle-clonus,  and  Babinski's  sign.  There  is  usually  a  slight  difficulty 
in  the  control  of  the  sphincters  which  appears  early.  The  skin  reflexes 
are  often  lost.  The  gait  is  usually  like  that  of  lateral  sclerosis,  the 
feet  drawn  along  the  floor  and  overlapping,  and  the  legs  stiff  and  ad- 
ducted.  The  entire  body  sways  in  walking,  which  is  due  to  an  irregu- 
lar contraction  of  the  muscles  of  the  trunk,  producing  what  Oppenheim 
has  termed  "vascillation." 

At  the  same  time  a  tremor  or,  rather,  a  jerky,  irregular  action  of 
the  hands  appears  which  is  increased  by  effort,  both  to  hold  them  still 
and  to  perform  any  fine  motion.  The  rate  of  the  tremor  is  from  five 
to  seven  per  second.  This  is  termed  by  Germans  the  "intention 
tremor,"  for  it  subsides  on  ceasing  to  make  effort. 

The  pupils  are  in  the  early  stages  contracted  and  then  irregular, 
but  always  respond  to  light.  Temporary  attacks  of  blindness  may  oc- 
cur, which  are  often  followed  by  a  permanent  condition,  due  to  optic 
atrophy;  in  fact,  optic  atrophy  may  be,  as  in  tabes,  the  earliest  symp- 
tom. It  is  a  pecuHarity  of  the  defects  of  vision  in  multiple  sclerosis 
that  they  vary  from  day  to  day,  at  times  disappearing  entirely.  Ver- 
tigo is  a  common  symptom. 

Mental  disturbances  are  also  common,  consisting  of  a  loss  of  con- 
trol, such  as  causeless  laughing,  which  are  frequently  accompanied  by 
a  sense  of  general  well-being,  but  not  with  the  delusions  of  grandeur 
characteristic  of  paresis.  The  patient,  instead,  acts  as  if  he  were  hys- 
teric, often  leading  to  difficulty  of  diagnosis  from  hysteria.  Attacks 
of  an  epileptiform  character  occur,  followed  in  some  cases  by  hemiplegic 
and  aphasic  disturbances.  Among  the  spinal  symptoms  loss  of  control 
of  the  sphincters  may  occur  early,  as  above  remarked. 

As  the  disease  progresses  bulbar  symptoms  begin  to  develop,  con- 
sisting of  difficulty  in  deglutition,  which  are  of  serious  import. 

The  duration  of  this  disease  is  very  uncertain,  some  reported  cases 
dying  within  twenty  months  from  the  first  symptoms,  while  others  last 
for  over  twenty  years.  It  is  due  to  the  spontaneous  occurrence  of  de- 
cided remissions  in  the  disease,  which  themselves  are  very  difficult  to 
account  for,  that  the  prognosis  is  so  uncertain ;  but  an  early  termination 
may  be  expected  upon  the  supervention  of  the  bulbar  symptoms  which 
we  have  described. 

Treatment. — Nothing  but  general  rules  can  be  prescribed  for  treat- 
ment. Muscular  exertion,  whether  general  or  local,  should  be  avoided; 
in  no  other  disease  does  the  prolonged  recourse  to  the  rest  cure  seem  so 
advantageous.  Among  medicinal  remedies,  cod-liver  oil,  conjoined  with 
warm,  but  not  hot,  saline  baths,  in  imitation  of  the  Nauheim  baths, 


AMYOTROPHIC   LATERAL    SCLEROSIS  559 

seem  to  be  beneficial,  but,  as  the  disease  is  characterized  by  remark- 
able spontaneous  remissions,  the  actual  results  due  to  treatment  re- 
main uncertain. 

The  disease  is  extremely  imcommon  in  America,  for,  though  I  have 
seen  cases  in  hospital  practice  and  in  my  clinics,  I  have  had  only 
one  patient  with  this  complaint  in  private  practice.  In  Europe, 
however,  it  seems  to  be  much  more  common,  especially  in  Germany. 

AMYOTROPHIC  LATERAL  SCLEROSIS 

This  affection  differs  from  chronic  anterior  poliomyelitis  not  only 
by  its  not  being  limited  to  the  anterior  horns  of  the  spinal  cord,  but 
also  by  its  involving  the  upper  segment  of  the  motor  tract,  reaching 
from  the  motor  region  in  the  cortex  of  the  brain  downi  to  its  distribu- 
tion around  the  cells  of  the  anterior  horns  of  the  spinal  cord.  In 
other  words,  it  involves  the  whole  motor  tracts,  from  the  cortex  of  the 
brain  down  to  the  feet. 

Symptoms. — Its  symptoms  in  general  are,  therefore,  divided  into 
two  classes:  the  first  being  those  of  paralysis,  beginning  in  the  fingers 
and  involving  the  muscles  of  the  hand,  forearm,  and  shoulder,  which 
are  simply  paralyzed;  and  then  the  muscles  of  the  legs,  which  present 
all  the  symptoms  of  spastic  paralysis.  In  its  course  its  symptoms 
develop  irregularly,  sometimes  those  of  paralysis  and  atrophy  in  the 
arms,  and  then  in  the  legs,  resembling  there  the  condition  found  in 
spastic  paraplegia.  Due  to  this  irregular  development  in  some  cases 
the  earher  symptoms  are  those  of  simple  bulbar  paralysis,  but,  as  time 
elapses,  the  other  symptoms,  either  in  the  arms  or  legs,  show  the  true 
nature  of  the  disease.  If  it  begins  in  the  arms,  the  signs  are  chiefly 
those  of  paralysis  and  atrophy  of  the  fingers  and  hands,  and  then  those 
of  the  upper  extremities,  until  the  arms  hang  helpless  and  cannot  be 
raised.  When  all  the  symptoms  are  well  developed  in  the  upper  ex- 
tremities the  arms  are  adducted  to  the  body,  the  forearms  are  pronated, 
and  the  hands  flexed  or  in  the  position  of  main  en  griff e.  There  is  some 
resistance  offered  to  passive  movements,  as  the  muscles  are  rigid  and 
spastic  even  when  quite  weak. 

When  the  disease  begins  in,  or  in  time  involves,  the  lower  extremities, 
the  symptoms  are  then  closely  similar  to  those  of  spastic  paraplegia. 
The  muscles  are  all  rigid,  the  knee-jerks  and  ankle-clonus  are  exagger- 
ated, the  walking  is  difficult  from  the  stiffness  of  the  legs,  the  step  being 
very  short,  with  a  scraping  of  the  toes.  There  is  no  involvement,  how- 
ever, of  the  bladder  or  rectum,  and  no  primary  sensory  symptoms,  nor 
is  there  any  locahzed  anesthesia  or  paresthesia.     The  symptoms  may 


560  CLINICAL  MEDICINE 

not  begin  in  both  legs  at  the  same  time,  and  in  the  early  stage  there  is 
no  fibrillary  twitching.  As  in  other  similar  disorders,  the  disease  may 
seem  to  come  to  a  standstill  for  a  while,  but  no  permanent  improve- 
ment is  to  be  expected.  When  the  disease  progresses  the  spastic 
rigidity  of  the  muscles  so  increases  that  the  patient  has  to  take  to  his 
bed.  After  a  time  the  spastic  rigidity  gives  place  to  the  same  flaccid 
paralysis  already  present  in  the  arms.  In  the  neck  the  paralysis  may  in 
time  involve  the  muscles  which  support  the  head,  so  that  it  falls  forward. 

One  of  the  characteristic  symptoms  of  the  disease  is  the  great  in- 
crease in  the  muscular  irritabiHty  in  all  the  muscles  that  are  affected. 
Percussion,  either  on  the  muscle  or  on  its  tendon,  causes  a  quick,  un- 
usually sharp  contraction,  and  this  exaggeration  of  reflex  activity 
throughout  the  entire  body,  both  in  the  muscles  that  are  atrophic  and 
in  those  that  are  spastic,  is  characteristic  of  the  disease,  and  is  not 
present  in  progressive  muscular  atrophy.  This  is  particularly  well 
illustrated  in  the  muscles  of  mastication,  which,  when  tapped,  produce 
a  prompt  closing  of  the  jaw.  The  disease  may,  in  its  progress,  involve 
the  muscles  of  the  back,  so  that  the  patient  can  no  longer  sit  up  in  bed. 
Rapid  action  of  the  heart  may  then  set  in,  and  is  a  grave  symptom,  often 
preceding  death. 

Meanwhile  the  psychical  functions  of  the  brain  remain  undisturbed, 
consciousness  and  memory  being  unaffected,  the  only  change  being 
emotional,  so  that  the  patient  may  laugh  or  cry  from  weakness  of  self- 
control. 

The  duration  of  the  disease  depends  upon  the  parts  first  affected. 
If  bulbar  symptoms  set  in  early,  the  case  is  not  apt  to  last  beyond  two 
years.  If,  however,  the  symptoms  are  chiefly  those  of  lateral  sclerosis, 
the  patient  may  live  for  a  number  of  years.  Aggravation  of  the  bulbar 
symptoms  usually  carry  off  the  patient  by  intercurrent  pneumonia, 
but  speedy  death  often  follows  the  development  of  tachycardia,  soon 
succeeded  by  heart  failure. 

Treatment. — We  have  no  remedies  of  much  avail  in  the  treatment  of 
this  affection  other  than  those  general  nutritive  agents  which  we  have 
already  spoken  of  in  the  treatment  of  chronic  anterior  poliomyelitis. 

ACUTE  ANTERIOR  POLIOMYELITIS 

This  affection  occurs  in  two  quite  distinct  forms,  the  first  of  which 
is  the  sporadic,  which  has  been  known  for  a  very  long  time;  the  second, 
and  a  very  different  affection,  is  that  which  occurs  epidemically,  and 
whose  medical  history  is  much  more  recent.  The  incidence  of  both 
forms  are  almost  limited  in  their  occurrence  to  children. 


ACUTE    ANTERIOR    POLIOMYELITIS  56 1 

Sporadic  poliomyelitis  and  epidemic  poliomyelitis  are  two  distinct 
affections,  differing  both  in  their  cause  and  in  their  nature.  Sporadic 
poliomyelitis  is  plainly  as  accidental  an  affection  as  a  broken  leg.  A 
child,  when  heated  in  play,  sits  on  a  cold  door-step,  or  lies  down  on  cold 
ground,  and  that  night  wakes  up  with  a  backache,  which  is  commonly 
associated  with  slight  fever,  usually  not  rising  above  102°  F.  In  the 
morning  it  is  found  unable  to  move  its  legs.  After  a  few  days  one  of 
its  disabled  legs  recovers  gradually  but  completely,  but  not  so  the  other, 
certain  groups  of  its  muscles  remaining  paralyzed,  and  then  undergo- 
ing an  atrophy  which  lasts  for  Ufe.  The  pomt,  however,  which  we 
would  here  emphasize  is,  that  none  of  this  child's  young  brothers  or 
sisters,  nor  any  of  its  companions,  catch  this  disabiUty  from  it,  because 
it  is  no  more  communicable  than  a  sprained  ankle  or  a  dislocated 
shoulder.  There  is  no  case  on  record  of  this  long,  well-known  form  of 
sporadic  poliomyeHtis  spreading  from  one  person  to  another  and  thus 
becoming  epidemic. 

But  there  is  a  poliomyelitis  which  is  epidemic.  This  fact  of  itself 
should  call  for  investigation,  to  find  whether  this  form  does  not  show 
characters  which'whoUy  separate  it  from  our  old  familiar  sporadic  form. 
Affections  like  inflammations  of  joints,  which  have  certaui  features  in 
common,  are  often  confounded  together,  such  as  rheumatism  and  gout. 
But  neither  rheumatism  nor  gout  differ  so  essentially  from  one  another, 
as  on  investigation  we  find  to  be  the  case  between  sporadic  and  epi- 
demic poliomyeHtis.  This  difference  is  clearly  illustrated  by  the  find- 
ings of  pathologic  anatomy.  In  the  sporadic  form  only  the  anterior 
horns,  with  their  motor  fibers,  are  changed,  the  affection  being  strictly 
limited  to  parts  of  the  spmal  cord  supplied  by  a  branch  of  the  anterior 
spinal  artery. 

This  artery  is  very  long,  virtually  commencuig  at  the  foramen  mag- 
num, and  continuuig  all  the  way  down  in  its  groove  on  the  anterior 
surface  of  the  spinal  cord,  until  it  terminates  ui  branches  supplyuig  the 
Cauda  equina  in  the  sacrum. 

There  is  first  in  the  sporadic  form  an  active  congestion  of  the  spuial 
menuiges  and  of  the  gray  matter  of  the  spinal  cord  supplied  by  the 
branches  of  the  anterior  spinal  artery.  From  the  anterior  spinal  artery 
about  one  hundred  branches  are  given  off,  which  enter  the  cord  hori- 
zontally at  various  segments,  supplying  the  anterior  comua  without 
anastomoses.  Many  groups  of  cells  extend  more  than  |  mch,  and 
hence  are  supplied  by  more  than  one  branch  of  this  artery.  The  blood- 
vessels are  distended  and  some  of  the  capillaries  are  ruptured,  allow- 
ing extravasations  of   blood-cells;  the  perivascular  spaces  and  the 


562  CLINICAL  MEDICINE 

gray  matter  of  the  cord  are  filled  with  emigrating  luckocytes,  and  there 
is  a  considerable  exudation  of  serum.  The  serum  fills  the  lymph-spaces 
about  the  vessels  and  about  the  nerve-cells;  the  leukocytes  infiltrate 
the  tissues  everywhere,  cluster  about  the  cells,  and  make  their  way  into 
the  cells.  This  destruction  of  the  cells  by  leukocytes  has  been  termed 
"neuronophagia."  There  is  also  a  great  increase  of  small  cells  and 
nuclei  throughout  the  neuroglia,  which  may  be  due  to  a  prohferation  of 
the  neuroglia  cells  or  of  the  endothelial  elements,  or  may  be  due  to  an 
emigration  from  the  blood-vessels.  This  infiltration  of  the  tissues  with 
leukocytes  and  nuclei  may  be  so  intense  as  to  obscure  all  other  ele- 
ments. It  is  thus  evident  that  the  blood-vessels  and  the  neuroglia,  as 
well  as  the  ganghon  cells  in  the  gray  matter  of  the  cord,  share  in  the 
pathologic  process. 

The  anatomic  changes  which  occur  in  a  sporadic  form  in  the  cells 
of  the  anterior  horns  are  very  definite  and  characteristic.  They  are 
characteristic  because  their  location  never  varies,  being  limited  to  the 
motor  anterior  horns  of  the  spinal  cord,  and  consist  essentially  of  a 
thorough  disorganization  of  the  cell  implicated,  as  we  have  described. 
This,  however,  is  complete  only  in  those  patients  in  which  a  permanent 
and  not  transitory  paralysis  and  atrophy  of  certain  groups  of  muscles 
persist;  in  the  leg,  for  example,  which  is  affected,  beginning  in 
the  earlier  stages  with  acute  congestion  and  inflammation  of  the  cells, 
which,  however,  varies  in  different  cases,  so  that  in  some  the  disorgan- 
ization is  but  moderate  and  admits  of  recovery. 

But  in  epidemic  poliomyeHtis  the  changes,  instead  of  being  limited, 
involve,  according  to  Flexner,  the  spinal  cord,  intervertebral  ganglia, 
medulla,  pons,  cerebellum,  and  meninges,  with  injury  to  the  white 
matter  of  both  the  spinal  cord  and  brain.  Moreover,  it  induces  serious 
changes  in  the  whole  lymphoid  tissue  of  the  body,  including  the  agmi- 
nated  glands  of  the  intestine.  Besides  these  there  occur  visceral 
lesions  in  the  lungs  and  in  the  liver. 

These  facts  readily  explain  another  significant  contrast  between  the 
two  affections.  Sporadic  poliomyelitis  but  rarely  causes  death  or 
even  much  constitutional  disturbance,  all  on  account  of  its  Hmited 
extent.  It  does  not  invade  the  posterior  horns  nor  cause  transverse 
myehtis,  nor  ascending  or  descending  cord  changes.  The  patients 
subsequently  enjoy  perfect  health,  with  the  exception  of  locaKzed 
paralysis.  Epidemic  poliomyelitis,  on  the  other  hand,  is  a  fatal  dis- 
ease, the  death-rate  varying  from  6  to  10  per  cent,  in  different  epidemics 
or  locahties.  In  epidemic  pohomyelitis,  notwithstanding  the  wide- 
spread derangements  which  it  occasions,  the  disease  usually  passes 


ACUTE    ANTERIOR    POLIOMYELITIS  563 

on  in  a  remarkably  short  time  to  complete  recovery  in  most  patients. 
This  is  another  striking  contrast,  for  the  disabling  results  of  sporadic 
poHomyelitis  are  both  invariable  and  hfe-long  in  their  duration. 

We  would,  therefore,  emphasize  anew  the  great  and  contrasting 
anatomic  changes  which  epidemic  poHomyeHtis  causes,  so  as  to  show 
that  these  two  alTections  no  more  resemble  one  another  than  small-pox 
resembles  urticaria.  Epidemic  pohomyehtis,  unHke  sporadic  polio- 
myehtis,  causes  enlargement  of  the  mesenteric  glands  and  enlargement 
of  the  spleen,  thymus,  tonsils,  and  superficial  and  deep  glands  of  the 
neck  and  focal  necroses  of  the  hver  cells,  besides  all  those  widespread 
changes  already  mentioned  in  the  substance  of  the  cord  and  brain. 
Hence  it  presents  all  the  characters  of  a  virulent  infection,  and,  there- 
fore, can  and  does  become  epidemic.  Also  that  instances  of  it  can 
occur  de  novo  or  sporadically  is  no  more  hkely  than  in  the  case  of 
typhoid  fever. 

Now,  as  we  have  said,  these  two  affections  differ  altogether  in  their 
etiology  and  pathology.  We  have  already  discussed  the  mechanism 
of  that  frequent  cause  of  disease  and  of  death,  commonly  termed 
"catching  cold"  ("Medical  Record,"  Feb.  17,  1912,  p.  301).  Catching 
cold  is  caused  by  some  locaHzed  shutting  off  of  arterial  blood  from  the 
part.  This  occurs  whenever  a  local  chill  affects  a  part  of  the  surface 
of  the  body  which  has  vasomotor  associations  with  internal  parts  or 
organs.  The  vasomotor  nerves  ramify  on  the  coats  of  the  arteries  so  as 
to  control  their  caHber,  either  contracting  or  dilating  same,  according 
to  the  functional  needs  of  the  part.  Among  other  laws  of  vasomotor 
association  which  we  cited  is  the  intimate  association  between  the 
vasomotor  nerves  of  the  skin  and  the  circulation  of  parts  underneath 
that  cutaneous  area.  No  cells  of  any  texture,  such  as  those  of  the 
mucous  membranes,  can  suffer  any  withdrawal,  however  brief,  of  any 
arterial  blood  without  injury.  But  this  is  particularly  the  case 
with  the  nerve-cells,  for  these  at  once  are  disorganized  by  the  shut- 
ting off  of  their  arterial  supply.  Hence,  if  a  child  has  a  local  chill 
on  any  part  of  the  skin  over  the  spinal  cord,  it  is  then  very  liable  to 
suffer  from  the  changes  in  its  arterial  circulation,  which,  in  this  case, 
are  limited  to  the  branches  of  the  anterior  spinal  artery. 

In  both  diseases,  we  have  children  affected  much  oftener  than  older 
patients.  This  may  be  explained  by  the  vulnerability  in  children  of 
the  spinal  cord  to  injuries,  especially  as  the  pyramidal  tracts  are  so  late 
in  their  development  and  thus  more  liable  to  derangement.  In  the 
sporadic  form  the  growth  of  the  leg  may  be  so  affected  as  to  become 
shorter  than  the  other,  and  from  the  first  its  vasomotor  nerves  are  so 


564  CLINICAL  MEDICINE 

involved  that  the  limb  becomes  cold.  As  time  goes  on  the  atrophied 
muscles  produce  not  only  lameness,  but  also  deformity  of  the  joints, 
which  have  to  be  specially  treated  so  as  to  compensate  for  this  dis- 
abihty.  Such  particular  and  localized  changes  do  not  occur  in  the 
epidemic  form. 

The  incidence  of  the  epidemic  form  is  striking  according  to  the 
season  of  the  year — namely,  during  the  summer  months — -while  the 
sporadic  form  commonly  occurs  during  cold  weather.  The  epidemic 
form  has  occurred  in  Europe  in  scattered  locahties — in  France,  Italy, 
Germany,  and  Denmark,  more  especially  in  Sweden.  In  the  United 
States  it  has  been  very  prevalent,  occurring  in  the  majority  of  the  States 
of  the  Union.  There  can  be  no  question  that  the  epidemic  form  is  of 
the  nature  of  an  infection,  and,  therefore,  the  question  of  its  communi- 
cabiHty  is  of  great  importance;  that  is,  whether  it  may  be  directly 
commimicated,  so  that  it  may  be  properly  termed  ''contagious,"  or 
indirectly,  as  in  typhoid  fever,  by  some  intermediate  carrier.  Such 
a  question  cannot  well  be  determined  in  crowded  cities,  hence  the 
importance  of  a  careful  study  of  the  epidemics  in  purely  rural  communi- 
ties. Thus,  I  was  called  in  consultation  to  see  a  boy  Kving  in  an  agri- 
cultural neighborhood  in  Dutchess  County,  New  York.  He  was  then 
paralyzed  in  both  legs,  and  had  considerable  difficulty  in  micturition, 
which  never  occurs  in  the  sporadic  form.  I  learned  that  the  boy  who 
sat  next  to  him  on  a  bench  in  a  schoolhouse  had  been  taken  with  the 
disease  eight  days  previously  and  died  from  it  in  four  days.  I  was  then 
taken  three  miles  to  a  house  in  which  a  young  woman  was  comatose, 
with  all  the  symptoms  of  cerebrospinal  meningitis,  from  which  she  died. 
I  then  learned  that  the  boy  whom  I  first  saw  was  a  cousin  of  hers,  and 
that  he  slept  in  her  house  for  two  nights  five  days  previous  to  the  first 
symptoms  which  she  developed.  So  far  as  these  cases  went,  there- 
fore, they  would  indicate  _  that  the  disease  was  communicated 
directly  from  one  patient  to  another.  I  urged  the  physicians  who 
called  me  in  consultation  to  ask  for  a  committee  of  their  county 
medical  society  to  investigate  the  succession  of  cases  in  a  district 
of  about  twelve  square  miles,  where  people  were  very  likely  to  be 
acquainted  with  one  another,  impressing  upon  them  the  importance 
of  such  observations  being  made  there,  compared  with  any  observa- 
tions in  large  towns  or  cities ;  but,  though  I  offered  to  present  their  re- 
ports before  the  New  York  Academy  of  Medicine,  of  which  I  was  then 
president,  I  heard  nothing  more  on  the  subject. 

In  the  widespread  epidemic  of  poHomyeHtis  in  the  city  of  New  York 
three  years  ago  the  symptoms  of  the  disease  were  often  scarcely  dis- 


ACUTE    ANTERIOR    POLIOMYELITIS  565 

tinguishable  from  those  of  cerebrospinal  meningitis,  a  fact  not  sur- 
prising, considering  how  often  epidemic  poIiomyeUtis  begins  in  the 
blood-vessels  of  the  meninges.  Epidemic  poliomyelitis,  when  it  occurs 
in  rural  communities,  is  plainly  a  communicable  disease,  and  hence 
the  profession  should  take  steps  to  have  it  thoroughly  investigated  by 
competent  observers  whenever  an  isolated  epidemic  is  reported.  In 
large  cities,  on  the  other  hand,  it  is  often  impossible  to  settle  how  any 
infectious  disease  is  propagated,  whether  it  be  measles,  diphtheria, 
whooping-cough,  or  the  rest.  The  one  practical  conclusion  is  that,  if 
any  infection  is  suspected  to  be  directly  communicable,  the  only 
measure  then  to  deal  with  it  should  be  by  isolation  or  quarantine. 

Though  uncommon  in  the  sporadic  form,  cases  have  been  reported 
in  which  the  arm  and  shoulder  are  involved.  If  in  the  arm,  the 
muscles  of  the  forearm,  including  those  of  the  wrist  and  fingers,  are 
affected  in  groups.  The  extensors  and  flexors  of  the  fingers  and  the 
wrists,  with  the  supinator  longus,  maybe  affected,  due  most  probably 
to  the  proximity  in  the  cord  of  the  centers  of  muscles  which  are  func- 
tionally associated  together. 

Treatment. — As  the  onset  of  sporadic  poliomyelitis  is  usually  sud- 
den the  child  retires  to  bed  apparently  in  its  normal  state  of  health, 
but  wakes  in  the  morning  with  its  legs  paralyzed,  and  is,  unfortunately, 
not  amenable  to  treatment  at  this  stage.  Local  applications  of  coun- 
terirritants  to  the  spine  are  quite  useless.  If  the  child  complains  of 
much  pain,  phenacetin  may  be  used  every  four  hours  in  5-gr.  doses, 
otherwise  nothing  can  be  done  but  to  keep  the  child  quiet  in  bed  for  a 
week.  After  this  a  careful  examination  as  to  the  responses  of  indi- 
vidual muscles  to  electric  excitations  should  be  begun,  to  find  if  any  of 
the  muscles  respond  readily  to  the  interrupted  Faradic  current. 
The  prognosis  is  good,  but  not  so  where  the  so-called  reaction  of 
degeneration  occurs,  for  in  this  there  is  loss  of  all  reaction  in  the 
Faradic  current,  and,  instead,  a  slow  imperfect  reaction  to  the  gal- 
vanic current,  noticeable  on  the  application  of  the  anode,  but  not  of  the 
cathode,  and  finally  even  this  reaction  is  lost.  Soon  it  is  found  that  the 
affected  muscles  are  not  only  paralyzed,  but  rapidly  atrophy,  a  change 
which  also  occurs  in  the  bones,  leading  to  shortening  of  the  Hmb,  com- 
pared with  its  fellow ;  but  as  these  changes  are  limited  after  a  while  to 
only  certain  groups  of  muscles,  while  others  remain  intact,  the  tendency 
in  time  results  in  deformity  of  the  joints,  due  to  the  unequal  pull  on 
them  of  the  non-paralyzed  and  the  paralyzed  muscles.  These  de- 
formities in  time  can  only  be  treated  by  a  specially  adjusted  apparatus. 
Meanwhile,  in  the  early  stages,  careful  inspection  may  show  that  some 


566  CLINICAL  MEDICINE 

muscles,  especially  those  which  react  to  the  Faradic  stimulus,  are 
capable  of  much  improvement  in  their  functions  by  massage.  This 
should  be  performed  with  the  help  of  the  hand,  lubricated  with  cocoa- 
nut  or  olive  oil,  the  massage  being  at  first  only  once  a  day,  for  twenty 
minutes  at  a  time,  but  afterward  twice  a  day,  night  and  morning. 
Electricity,  however,  is  of  httle  value  in  confirmed  cases,  and  all 
measures  should  be  adopted  to  improve  the  general  nutrition  and  the 
child  kept  as  much  as  possible  in  the  open  air. 

In  the  epidemic  form,  as  might  be  expected  with  any  serious  infec- 
tion, we  have  no  real,  efficacious  remedies,  and  must  trust  to  nature. 
While  severe  cases  end  in  death  in  from  6  to  10  per  cent,  of  all  patients, 
complete  recoveries,  without  any  of  the  resulting  local  paralysis 
characterizing  the  sporadic  form,  may  be  expected.  In  fact,  it  is  re- 
markable how,  notwithstanding  the  extensive  textural  changes  which 
characterize  the  epidemic  form,  the  ultimate  recovery  from  them  all  is 
often  striking. 

During  the  acute  onset  the  patients  often  complain  of  severe  pains, 
such  as  those  which  occur  in  cerebrospinal  meningitis,  and,  like  them, 
may  respond  favorably  to  free  doses  of  the  fluidextract  of  ergot,  com- 
bined with  5-  to  lo-gr.  doses  of  phenacetin. 

For  further  illustration  in  the  contrasts  between  these  two  affec- 
tions we  subjoin  the  following  table : 

Sporadic.  Epidemic. 

Never  infectious  or  epidemic.  Always  due  to  an  infectious  filterable  virus 

which  can  become  epidemic. 

Due  to  a  cold  affecting  some  branches  of  Always  due  to  an  infection. 

the  anterior  spinal  artery. 

Usually  beginning  with  febrile  symptoms  Usually   but   not    always   beginning   with 

like  any  other  cold.  febrile  symptoms. 

Complete  recovery  rare,  particular  groups  Usually  complete  recovery,  localized  paral- 

of  muscles  remaining  paralyzed.  ysis  uncommon. 

Not  fatal.  Fatal  in  from  6  to  10  per  cent. 

No  more  prospect  of  antisera  than  there  Antisera  probable  as  in  other  infections. 

can  be  a  sera  for  a  broken  leg. 

CHRONIC  ANTERIOR  POLIOMYELITIS 
Chronic  Atrophic  Paralysis.     Progressive  Muscular  Atrophy 

This  disease  has  been  long  recognized  as  characterized  by  paralysis 
and  atrophy  of  the  skeletal  muscles  of  a  progressive  form,  usually 
beginning  in  the  lower  extremities,  and  identified  by  Aran  as  con- 
nected with  the  degeneration  of  the  anterior  horns  of  the  spinal  cord, 
similar  to  that  which  we  have  been  reviewing  in  the  acute  paralysis 
among  children.     The  only  differences  are  its  more  chronic  coarse,  the 


CHRONIC    ANTERIOR    POLIOMYELITIS  567 

cells  of  the  anterior  horn  being  found  disorganized  in  the  same 
fashion  as  they  are  in  the  anterior  pohomyelitis  of  children,  and  that 
it  occurs  among  adults,  being  a  progressive  disease,  advancing  upward 
to  the  trunk,  until  it  finally  involves  the  cells  that  supply  the  muscles 
of  respiration,  and  thus  causes  death. 

But  between  i860  and  1870  numerous  cases  of  atrophic  paralysis 
were  reported  in  which  no  spinal  lesion  was  to  be  found,  and  hence  it 
became  evident  that  some  forms  of  this  disease  were  dependent  not  on 
spinal  lesions,  but  on  primary  affections  of  the  muscles. 

To  Friedreich  and  the  German  school  must  be  given  the  credit 
of  separating  the  muscular  dystrophies  from  the  forms  of  true  spinal 
paralysis. 

In  1872  Charcot  and  the  French  school  discovered  amyotrophic 
lateral  sclerosis,  and  showed  the  difference  between  it  and  progressive 
muscular  atrophy.  In  time  Dejerine  and  other  French  authors  showed 
that  many  cases,  formerly  supposed  to  be  due  to  spinal  disease,  were 
really  cases  of  multiple  neuritis. 

In  chronic  anterior  pohomyelitis  this  disease  consists  of  a  slowly 
advancing  atrophy  in  the  primary  motor  neurones  of  the  cord,  cell 
bodies,  dendrites,  and  axones  degenerating  together.  This  disease 
causes  s5rmptoms  according  to  the  part  of  the  spinal  cord  which  is 
attacked;  thus,  in  one  form  the  atrophy  begins  in  the  lower  groups  of 
cells  of  the  lumbosacral  region  and  extends  to  all  the  groups  in  the 
lumbar  enlargement,  but  in  all  cases  of  muscular  atrophy  from  spinal 
disease  the  affected  muscles  for  a  long  time  after  the  beginning  of  the 
disorder  present  fibrillary  contractions  recognizable  under  the  skin. 
These  slight  twitchings  do  not  affect  the  whole  muscle,  but  are  pres- 
ent only  in  limited  strands,  and  can  be  caused  either  by  exposure 
to  cold  or  by  tapping  the  muscle  itself.  The  paralysis  begins  in  the 
peronei  and  anterior  tibial  groups  of  muscles,  then  advances  to  the 
adductors  of  the  thigh  and  glutei,  and  finally  invades  all  the  muscles 
of  the  legs,  but  does  not  extend  to  the  arms. 

In  the  next  form  the  disease  slowly  progresses  upward  until  the 
cells  of  the  anterior  horns  are  found  degenerated  quite  up  to  the  cervical 
enlargement.  As  it  thus  progresses,  the  cells  supplying  the  muscles  of 
respiration  are  involved,  with  a  result  of  causing  death  by  impKcation 
of  the  apparatus  of  breathing.  Commonly,  however,  the  patient  suc- 
cumbs to  intercurrent  affections,  such  as  pneumonia,  before  the  spinal 
degenerations  are  complete. 

In  some  cases  the  disease  seems  to  be  limited  first  to  the  cervical 
regions,  before  the  cells  of  the  lumbar  enlargement  are  involved.     When 


568  CLINICAL  MEDICINE 

this  occurs  the  muscles  of  the  shoulder,  such  as  the  deltoid  and  brachia- 
lis  anticus,  are  affected.  The  arm  then  hangs  helpless  and  cannot  be 
raised.  It  is  significant,  however,  that,  whether  the  paralysis  involves 
the  legs  or  the  arms,  yet  in  none  of  these  anatomic  changes  in  the  spinal 
cord  are  its  membranes  affected,  the  changes  noted  being  evident 
only  on  microscopic  examination  as  those  of  simple  degeneration  of 
the  cells  and  of  their  axones  and  dendrites,  without  a  sign  of  any  inflam- 
matory process,  from  which  we  would  infer  that  the  whole  process  is 
of  toxic  origin  and  nature,  extending  to  all  the  groups  of  association 
fibers. 

The  symptoms  of  this  disease,  when  it  affects  the  legs,  usually  begin 
in  one  leg,  and  then  after  two  or  three  months  extend  to  the  other  leg. 

Treatment. — On  account  of  our  ignorance  of  the  causes  in  the  wast- 
ing of  spinal  tracts  which  characterize  this  disease  we  have  no  means 
of  successfully  treating  it,  and  can  only  proceed  according  to  general 
principles.  Cases  occur  in  which  apparent  spontaneous  arrest  in  the 
progress  of  the  complaint  occurs,  but  these  are  usually  temporary. 
Hypodermic  use  of  strychnin  in  :^-gr.  doses  has  been  employed,  but, 
in  my  opinion,  is  useless,  except  as  a  possible  adjuvant  to  those  more 
promising  agents  for  improving  the  general  nutrition,  such  as  cod- 
liver  oil  and  intermittent  use  of  arsenic.  The  affected  muscles  should 
not  be  exercised,  because  in  them  fatigue  is  quickly  induced,  and  after 
fatigue  the  disease  progresses  more  rapidly,  but  the  patient  should  be 
allowed  to  take  the  open  air  as  much  as  possible  in  a  rolling  chair. 
Massage  of  the  muscles  with  olive  oil  may  be  tried  once  or  twice  a  day, 
but  even  this  passive  exercise  should  not  last  more  than  twenty  minutes 

at  a  time. 

BULBAR  PARALYSIS 

By  bulbar  paralysis  is  meant  a  disease  which  involves  the  motor 
nuclei  found  in  the  floor  of  the  fourth  ventricle.  It  occurs  commonly 
as  a  complication  in  the  progress  of  chronic  wasting  affections  of  the 
spinal  cord,  such  as  in  amyotrophic  spinal  paralysis,  which  we  have 
already  described.  Occasionally  it  assumes  an  acute  form,  due  to 
hemorrhage  or  occlusion  of  the  arteries  supplying  the  centers  in  the 
floor  of  the  fourth  ventricle.  When  its  symptoms  develop  rapidly, 
as  a  result  of  the  necrosis  of  the  parts  in  the  floor  of  the  fourth  ven- 
tricle, the  first  signs  are  paralysis  of  the  lips,  which  remain  open, 
with  droohng  of  the  saliva;  along  with  this  is  paralysis  of  the  tongue, 
which  becomes  atrophied  and  shows  fibrillary  twitchings.  The  more 
serious  symptoms,  however,  are  those  of  paralysis  of  deglutition,  which, 
conjoined  with  paralysis  of  the  vocal  chords,  renders  both  phonation  and 


SYRINGOMYELIA  569 

speaking  indistinct,  these  affections  all  contributing  to  fits  of  choking 

from  particles  of  food  entering  the  larynx,  and  thus  inducing  fatal 

pneumonia. 

SYRINGOMYELIA 

The  central  canal  of  the  spinal  cord  possesses  a  peculiar  interest 
because  it  consists  virtually  of  the  remains  of  the  earliest  structure 
which  appears  in  the  development  of  the  spinal  cord  itself,  being  a 
canal  around  which  all  the  structures  of  both  the  gray  and  white  matter 
of  the  cord  subsequently  develop.  When  this  occurs  this  canal  would 
seem  as  if  it  were  obHterated,  which  is  never  the  case,  but  remains 
through  Hfe  as  a  minute  canal,  extending  through  the  whole  length  of 
the  spinal  cord  from  the  fourth  ventricle  down  to  the  conus  meduUaris 
in  the  sacrum.  On  account  of  its  origin  it  is  lined  by  a  peculiar  glioma- 
tous  layer  of  cells,  which  belong  plainly  to  primitive  embryonal  tissues. 

In  the  disease  called  syringomyelia  this  central  canal  becomes  di- 
lated in  a  very  irregular  fashion  with  fluid  accumulating  in  it,  which  leads 
to  numerous  secondary  changes,  sometimes  of  the  nature  of  diverticula 
themselves,  occasionally  the  diverticula  being  so  long  as  to  obscure  the 
course  of  the  central  canal  itself.  But  the  original  gliomatous  struc- 
ture still  remains,  so  that  authors  speak  of  the  disease  as  a  gUosis  of 
the  spinal  cord.  A  great  many  theories  have  been  advanced  as  to 
the  origin  and  cause  of  this  disease,  but  the  most  probable  one  is  that 
it  is  due  to  a  -congenital  defect  in  the  development  of  the  spinal  cord, 
dilatations  occurring  along  the  course  of  the  central  canal,  which  may  be 
very  irregular  in  their  location  and  in  their  extent.  When  the  fluid 
is  let  out  in  such  cases  the  cord  seems  to  be  shrunken  in  parts.  Occa- 
sionally these  accumulations  have  been  so  great  that  but  a  thin  wall  of 
normal  cord  tissue  remains.  The  common  site  is  in  the  cervical  re- 
gions, and  especially  involving  the  posterior  structures  of  the  cord, 
but  cases  occur  in  which  the  extent  may  be  nearly  that  of  the  whole 
length  of  the  cord.  As  might  be  easily  inferred,  the  symptoms  of 
this  affection  are  very  numerous  and  complex,  so  that  but  for  ^the 
great  peculiarity  of  disorders  of  sensation  in  the  parts  involved  the 
diagnosis  might  be  very  difficult,  but  that  peculiarity  is  significant 
enough  to  make  the  nature  of  the  complaint  quite  plain.  It  con- 
sists in  a  dissociation  of  the  three  senses — of  touch,  of  pain,  and  of 
the  appreciation  of  heat  and  of  cold,  or  the  thermic  sense.  Thus,  the 
sense  of  touch  in  the  affected  part  may  be  preserved,  while  the  sense 
of  pain  is  lost,  and  with  it  the  thermic  sense,  the  patient  being  unable 
to  distinguish  between  the  application  of  a  test-tube  filled  with  hot 
water  or  ice- water. 


570  CLINICAL   MEDICINE 

Meanwhile  the  results  of  internal  pressure  on  the  different  spinal 
tracts  may  produce  both  paralysis  and  spasm  characteristic  of  amyo- 
trophic paralysis.  If  the  pressure  is  mainly  on  the  posterior  column 
the  symptoms  may  resemble  those  of  tabes,  bat,  in  any  case,  the  sepa- 
rate dissociation  of  the  sense  of  touch  from  that  of  pain  or  of  heat  and 
cold  will  settle  the  diagnosis. 

This  disease  reveals  to  us  what  some  of  the  paths  in  the  spinal  cord 
of  sensation  are.  Thus,  the  upward  paths  of  the  sensation  of  pain  and 
of  temperature  differ  in  their  location  from  the  sense  of  touch,  for  they 
pass  into  the  central  portion  of  the  gray  matter  of  the  spinal  cord  soon 
after  their  entrance. 

"It  is  certain  that  their  entire  course,  from  below  upward,  is  not 
in  the  gray  matter;  otherwise  a  limited  lesion  of  this  portion  in  the  cer- 
vical segments  would  produce  a  disturbance  of  these  senses  in  the  entire 
body  below  the  lesion;  but  it  appears  that  these  sensations,  on  their 
way  from  the  surface  of  the  body  to  the  centripetal  white  columns  of 
the  cord  (the  anterolateral  tracts),  traverse  the  gray  matter  at  the 
level  at  which  they  enter;  hence  the  distribution  of  this  disturbance  of 
sensibiUty  corresponds  exactly  to  the  position  of  the  lesion  in  the  spinal 
cord"  (Starr).  As  the  various  segmental  cutaneous  areas  of  sensa- 
tion have  been  independently  determined,  it  is  possible  in  syringomyelia 
to  settle  the  precise  location  of  the  lesions  in  the  spinal  cord.  Thus,  as 
commonly  is  the  case,  syringomyeHa  begins  in  the  cervical  portion  of 
the  cord,  and  the  patients  are  first  made  aware  of  their  trouble  by  their 
fingers  being  no  longer  sensitive  to  pain,  so  that,  as  pain  is  the  great 
preservative  against  injury,  these  patients  suffer  various  injuries  to 
their  fingers  without  knowing  it.  When  the  disease  is  fully  established 
the  patient  cannot  distinguish  between  the  application  of  boiling  water 
or  ice  water,  and  his  fingers  may  be  cut  into  without  his  knowing  it; 
on  that  account  the  site  of  an  injury  may  become  seriously  infected 
by  micro-organisms  without  the  patient  knowing  why.  But  disturb- 
ances in  the  nutritional  part  also  occur  in  syringomyelia  without  it 
being  possible  to  assign  them  to  the  above-mentioned  causes;  on  that 
accoimt  this  disease  has  been  supposed  to  demonstrate  the  separate 
existence  of  a  class  of  nerves  called  trophic  nerves,  whose  function  is  to 
preside  over  nutrition,  especially  nutrition  of  the  skin.  "The  skin  is 
the  seat  of  the  chief  trophic  disturbances.  These  may  be  of  various 
kinds.  There  may  be  locaHzed  hyperemia  or  anemia  of  the  skin. 
There  may  be  changes  in  the  perspiration,  the  part  being  abnormally 
covered  with  sweat  or  abnormally  dry,  and,  in  addition  to  the  acute 
inflammation  of  the  skin  already  mentioned  as  produced  by  injuries, 


SYRINGOMYELIA 


571 


cases  have  been  observed  of  serous  exudation  with  desquamation, 
gangrene  of  the  skin  and  subcutaneous  tissue,  bullae,  and  pecuUar 
hypertrophies  and  atrophies  of  the  skin"  (Starr).  It  shoukJ  be 
noted,  however,  that  these  cutaneous  affections  are  not  symmetric; 
that  is,  they  do  not  occur  in  just  the  same  form  on  both  sides  of 
the  body. 

Morvan  has  described  a  disease  occurring  in  a  seaport  of  France 
among  fishermen,  consisting  of  felons  appearing  upon  the  fingers, 
producing  deep  ulcerations  and  even  necrosis  of  the  terminal  phalanges. 
These  were  associated  with  other  trophic  disturbances  of  the  skin  and 
nails  and  with  analgesia.  This  so-called  Morvan's  disease  is  now  con- 
sidered as  a  variety  of  syringomyeha,  because  in  all  cases  examined 
after  death  a  cavity  has  been  found  in  the  spinal  cord.  The  nails  also 
become  quite  distorted,  being  thickened  or  irregular  in  form  and  very 
brittle. 

Affections  of  the  joints  and  bones  are  frequently  observed  in  syringo- 
myeha.  In  fact,  there  is  no  nervous  disease  in  which  joint  affection 
occurs  so  commonly  as  a  complication;  the  shoulder,  elbow,  and  wrist 
are  the  joints  most  frequently  affected.  Affections  of  the  bones  and 
joints  are  common  in  syringomyelia,  but,  in  distinction  from  tabes,  they 
occur  more  often  in  the  upper  extremities  and  in  the  legs.  These 
affections,  however,  resemble  those  in  tabes  by  their  consisting  first 
of  large  effusions  within  the  joints,  which  are  then  absorbed,  leaving 
great  thickening  of  the  tissues,  with  absorption  of  the  bony  structure 
of  the  joint,  producing  disorganization  of  the  articulation. 

Nor  do  the  long  bones  escape,  for  irregular  development  of  the  bony 
tissues  occurs,  with  absorption  in  parts,  until  the  bones  may  spontane- 
ously fracture;  in  other  words,  all  processes  of  healing  are  disturbed  in 
this  strange  affection.  As  these  fractures  occur  without  pain,  they  may 
at  first  be  neglected  by  the  patient  until  revealed  to  him  by  their  con- 
sequent disabihty.  As  might  be  expected,  the  spinal  column  may  not 
escape,  and  various  deformities  of  the  spine  may  thus  occur. 

Accompanying  the  disease  also  of  the  bones  and  joints  they  neces- 
sarily develop  various  muscular  atrophies,  with  such  disablement  of 
movement  that  the  case  may  resemble  those  affections  which  we  have 
described  characteristic  of  chronic  anterior  poHomyeHtis  or  amyotro- 
phic spinal  paralysis.  From  this  affection,  however,  they  may  be  dis- 
tinguished, on  careful  examination,  by  the  pathognomonic  local  disso- 
ciation of  the  tactile  sense  from  the  sense  of  pain  and  the  thermic  sense. 

The  progress  of  the  disease  is  very  slow,  but  as  certain  instances 
show  that  the  whole  spinal  cord  becomes  involved,  the  consequent 


572  CLINICAL   MEDICINE 

symptoms  may  resemble  either  one  of  several  of  the  different  affec- 
tions of  the  cord  which  we  have  described,  such  as  the  formation  of 
bed-sores,  loss  of  control  over  the  sphincters,  etc. 

Treatment. — The  prognosis  of  the  complaint  is  necessarily  unfavor- 
able, as  we  have  no  effective  means  of  treating  it,  and  we  can  deal 
only,  and  that  imperfectly,  with  its  concomitant  symptoms. 

It  is  not  imcommon,  however,  for  the  disease  to  come  to  a  stand- 
still, though  we  cannot  explain  why,  and  meantime  our  chief  efforts 
should  be  to  maintain  the  general  nutrition  of  the  patient  as  much  as 

possible. 

BRACHIAL  PLEXUS 

Affections  of  the  branches  of  the  brachial  plexus  will  present  us 
with  s3nxiptoms  implicating  the  position  and  the  movements  of  the 
muscles  of  the  shoulder  and  of  the  arm  which  can  be  diagnosed  only 
according  to  the  physician's  knowledge  of  the  distribution  of  both  the 
motor  and  sensory  nerves  implicated. 

First,  there  may  be  an  anomaly  in  the  presence  of  a  cervical  rib, 
and  this  is  always  a  cause  of  annoyance,  which,  in  the  majority  of 
cases,  can  be  remedied  only  by  excision  of  the  rib.  The  commonest 
causes,  however,  of  brachial  neuritis  are  of  traumatic  origin,  such  as 
dislocation  of  the  head  of  the  humerus  into  the  axilla,  or  from  falls  or 
blows  on  the  part  involved. 

Affections  of  the  nerves  are  more  frequent  and  important.  Pain  is 
common,  corresponding,  as  a  rule,  to  the  distribution  of  the  eighth 
cervical  and  first  dorsal  roots,  extending  along  the  ulnar  border  of  the 
forearm  to  the  wrist  or  fingers.  In  other  cases  there  is  marked  press- 
ure on  the  brachial  plexus,  with  partial  paralysis  and  wasting  of  the 
intrinsic  muscles  of  the  hand.  There  may  be  anesthesia  or  hyperes- 
thesia of  the  inner  aspect  of  the  arm  and  the  ulnar  half  of  the  hand. 
In  a  few  instances  there  has  been  pressure  on  the  cervical  S3nnpathetic 
nerve. 

The  condition  is,  as  a  rule,  readily  recognized,  sometimes  by  pal- 
pation, always  with  the  :r-ray  picture. 

Combined  Paralysis. — The  plexus  may  be  involved  in  the  supra- 
clavicular region  by  compression  of  the  nerve  trunks  as  they  leave  the 
spine,  or  by  tumors  and  other  morbid  processes  in  the  neck.  Below, 
the  clavicle  lesions  are  more  common,  and  result  from  injuries  follow- 
ing dislocation  or  fracture,  sometimes  from  neuritis.  A  cervical  rib 
may  lead  to  a  pressure  paralysis  of  the  lower  cord  of  the  plexus.  A  not 
infrequent  form  of  injury  in  this  region  follows  falls  or  blows  on  the 
neck,  which,  by  lateral  flexion  of  the  head  and  depression  of  the  shoul- 


BRACHIAL    PLEXUS  573 

der,  seriously  stretches  the  plexus.  The  entire  plexus  may  be  ruptured 
and  the  arm  be  totally  paralyzed.  The  rupture  may  occur  anywhere 
between  the  vertebrae  and  the  clavicle,  and  involve  all  the  cords  of  the 
plexus  or  only  the  upper  ones.  The  so-called  "obstetric  palsy,"  due 
to  drawing  apart  of  the  head  and  the  shoulder  during  deHvery,  is  an 
instance  of  this  sort  of  injury.  In  these  cases,  however,  the  rupture 
of  the  plexus  is  usually  only  a  partial  one,  involving  its  upper  cord  alone, 
so  that  the  deltoid,  biceps,  supra-  and  infraspinatus,  brachialis  anticus, 
and  supinator  longus  muscles  may  alone  be  affected.  When  the  entire 
plexus  has  been  ruptured,  a  complete  motor  and  sensory  paralysis  of 
the  arm  is  produced.  The  roots  may  even  be  torn  away  from  the 
spinal  cord.  The  pupil  will  then  be  contracted  on  the  side  of  the  in- 
jury and  the  arm  hang  from  the  body  like  a  flail.  Another  common 
cause  of  lesion  of  the  brachial  plexus  is  luxation  of  the  head  of  the  hu- 
merus, particularly  the  subcoracoid  form. 

A  primary  neuritis  of  the  brachial  plexus  is  rare.  More  commonly 
the  process  is  an  ascending  neuritis  from  a  lesion  of  a  peripheral 
branch,  involving  first  the  radial  or  ulnar  nerves,  and  spreading  up- 
ward to  the  plexus,  producing  gradually  complete  loss  of  power  in  the 

arm. 

Lesions  of  Individual  Nerves  of  the  Plexus 

(a)  Long  Thoracic  Nerve. — Serratus  paralysis  follows  injury  to  this 
nerve  in  the  neck,  usually  by  direct  pressure  in  carrying  loads,  and  is 
very  common  in  soldiers.  It  may  be  due  to  a  neuritis  followuig  an 
acute  infection  or  exposure.  Isolated  serratus  paralysis  is  rare.  It 
usually  occurs  in  connection  with  paralysis  of  other  muscles  of  the 
shoulder-girdle,  as  ui  the  myopathies  and  in  progressive  muscular 
atrophy.  Concomitant  trapezius  paralysis  is  the  most  frequent.  In 
the  isolated  paralysis  there  is  little  or  no  deformity,  with  the  hands 
hanging  by  the  sides.  There  are  sHght  abnormal  obHquity  of  the  pos- 
terior border  of  the  scapula  and  prominence  of  the  inferior  angle,  but 
when,  as  so  commonly  happens,  the  middle  part  of  the  trapezius  is  also 
paralyzed,  the  deformity  is  marked.  The  shoulder  is  at  a  lower  level; 
the  superior  angle  projects  upward.  When  the  arms  are  held  out  in 
front  at  right  angles  to  the  body  the  scapula  becomes  winged  and 
■  stands  out  prominently.  The  arm  cannot,  as  a  rule,  be  raised  above 
the  horizontal.  The  outlook  of  the  cases,  due  to  injury  or  to  neuritis, 
is  good. 

{h)  Circumflex  Nerve. — This  supplies  the  deltoid  and  the  teres 
minor.  The  nerve  is  apt  to  be  involved  m.  injuries,  in  dislocations, 
bruising  by  a  crutch,  or  sometimes  by  extension  of  inflammation  from 


574  CLINICAL   MEDICINE 

the  joint.  Occasionally  the  paralysis  arises  from  a  pressure  neuritis 
during  an  illness.  As  a  consequence  of  loss  of  power  in  the  deltoid, 
the  arm  cannot  be  raised.  The  wasting  is  usually  marked,  and  changes 
the  shape  of  the  shoulder.  Sensation  may  also  be  impaired  in  the 
skin  over  the  muscle.  The  joint  may  be  relaxed,  and  there  may  be  a 
distinct  space  between  the  head  of  the  humerus  and  the  acromion. 

(c)  Musculospiral  Paralysis;  Radial  Paralysis. — This  is  one  of  the 
most  common  of  peripheral  palsies,  and  results  from  the  exposed  posi- 
tion of  the  musculospiral  nerve.  It  is  often  bruised  in  the  use  of  the 
crutch,  by  injuries  of  the  arm,  blows,  or  fractures.  It  is  frequently 
injured  when  a  person  falls  asleep  with  the  arm  over  the  back  of  a 
chair,  or  by  pressure  of  the  body  upon  the  arm  when  a  person  is  sleep- 
ing on  a  bench  or  on  the  ground.  It  may  be  paralyzed  by  sudden  vio- 
lent contraction  of  the  triceps.  It  is  sometimes  involved  in  a  neuritis 
from  cold,  but  this  is  uncommon  in  comparison  with  other  causes. 
The  paralysis  of  lead-poisoning  is  the  result  of  involvement  of  certain 
branches  of  this  nerve. 

A  lesion  when  high  up  involves  the  triceps,  the  brachiahs  anticus,  and 
the  supinator  longus,  as  well  as  the  extensors  of  the  wrist  and  fingers. 
Naturally,  in  lesions  just  above  the  elbow  the  arm  muscles  and  the 
supinator  longus  are  spared.  The  most  characteristic  feature  of  the  pa- 
ralysis is  the  wrist-drop  and  the  inabihty  to  extend  the  first  phalanges  of 
the  fingers  and  thumb.  In  the  pressure  palsies  the  supinators  are  usual- 
ly involved,  and  the  movements  of  supination  cannot  be  accompHshed. 
The  sensations  may  be  impaired,  or  there  may  be  marked  tinghng,  but 
the  loss  of  sensation  is  rarely  so  pronounced  as  that  of  motion. 

The  affection  is  readily  recognized,  but  it  is  sometimes  difficult 
to  say  upon  what  it  depends.  The  sleep  and  pressure  palsies  are,  as  a 
rule,  unilateral,  and  involve  the  supinator  longus.  The  paralysis  from 
lead  is  bilateral  and  the  supinators  are  unaffected.  Bilateral  wrist- 
drop is  a  very  common  symptom  in  many  forms  of  multiple  neuritis, 
particularly  the  alcohoHc ;  but  the  mode  of  onset  and  the  involvement 
of  the  legs  and  arms  are  features  which  make  the  diagnosis  easy.  The 
duration  and  course  of  the  musculospiral  paralyses  are  variable.  The 
pressure  palsies  may  disappear  in  a  few  days.  Recovery  is  the  rule, 
even  when  the  affection  lasts  for  many  weeks.  The  electric  examina- 
tion is  of  importance  in  the  prognosis,  and  the  rules  laid  down  under 
paralysis  of  the  facial  nerve  hold  good  here. 

The  treatment  is  that  of  neuritis. 

{d)  Ulnar  Nerve. — The  motor  branches  supply  the  ulnar  half  of 
the  deep  flexors  of  the  fingers,  the  muscles  of  the  little  finger,  the  inter- 


LUMBAR    PLEXUS  575 

ossei,  the  adductor  and  the  inner  head  of  the  short  flexor  of  the  thumb, 
and  the  ulnar  flexor  of  the  wrist.  The  sensory  branches  supply  the 
ulnar  side  of  the  hand — two  and  one-half  fingers  on  the  back,  and  one 
and  one-half  fingers  on  the  front.  Paralysis  may  result  from  pressure, 
usually  at  the  elbow-joint,  although  the  nerve  is  here  protected. 
Possibly  the  neuritis  in  the  ulnar  nerve  in  some  cases  of  acute  illness 
may  be  due  to  this  cause.  Gowers  mentions  the  case  of  a  lady  who 
twice  had  ulnar  neuritis  after  confinement.  Owing  to  paralysis  of  the 
ulnar  flexor  of  the  wrist,  the  hand  moves  toward  the  radial  side; 
adduction  of  the  thumb  is  impossible;  the  first  phalanges  cannot  be 
flexed,  and  the  others  cannot  be  extended.  In  long-standing  cases 
the  first  phalanges  are  overextended  and  the  others  strongly  flexed, 
producing  the  claw-hand;  but  this  is  not  so  marked  as  in  the  progress- 
ive muscular  atrophy.  The  loss  of  sensation  corresponds  to  the 
sensory  distribution  just  mentioned. 

(e)  Median  Nerve. — This  supplies  the  flexors  of  the  fingers,  except 
the  ulnar  half  of  the  deep  flexors,  the  abductor  and  the  flexors  of  the 
thumb,  the  two  radial  lumbricales,  the  pronators,  and  the  radial 
flexor  of  the  wrist.  The  sensory  fibers  supply  the  radial  side  of  the 
palm  and  the  front  of  the  thumb,  the  first  two  fingers  and  one-half  of 
the  third  finger,  and  the  dorsal  surfaces  of  the  same  three  fingers. 

"This  nerve  is  seldom  involved  alone.  Paralysis  results  from  in- 
jury and  occasionally  from  neuritis.  The  signs  are  inability  to  pronate 
the  forearm  beyond  the  mid-position.  The  wrist  can  be  flexed  only 
toward  the  ulnar  side;  the  thumb  cannot  be  opposed  to  the  tips  of  the 
fingers.  The  second  phalanges  cannot  be  flexed  on  the  first;  the  distal 
phalanges  of  the  first  and  second  fingers  cannot  be  flexed;  but  in  the 
third  and  fourth  fingers  this  action  can  be  performed  by  the  ulnar  half 
of  the  flexor  profundus.  The  loss  of  sensation  is  in  the  region  corre- 
sponding to  the  sensory  distribution  already  mentioned.  The  wasting 
of  the  thumb  muscles,  which  is  usually  marked  in  this  paralysis,  gives  to 
it  a  characteristic  appearance"  (Osier). 

Treatment. — The  only  treatment  which  I  have  found  efficacious  in 

these  distressing  cases  has  been  the  introduction  of  the  arm  into  the 

hot-air  box,  as  described  in  our  article  on  Sciatica.     Even  in  cases  of 

traumatic  origin  it  has  been   efficacious  when    every  other  measure 

had  failed. 

LUMBAR  PLEXUS 

"Lumbar  Plexus. — The  lumbar  plexus  is  sometimes  involved  in 
growths  of  the  lymph-glands,  in  psoas  abscess,  and  in  disease  of  the 
bones  of  the  vertebrae.     When  paralyzed  the  obturator  nerve  is  occa- 


576  ,  CLINICAL  MEDICINE 

sionally  injured  during  parturition.  When  paralyzed  the  power  is 
lost  over  the  abductors  of  the  thigh,  and  one  leg  cannot  be  crossed 
over  the  other.  Outward  rotation  is  also  disturbed.  The  anterior 
crural  nerve  is  sometimes  involved  in  wounds  or  in  dislocation  of  the 
hip-joint,  less  commonly  during  parturition,  and  sometimes  by  dis- 
ease of  the  bones  and  in  psoas  abscess.  The  special  symptoms  of 
affection  of  this  nerve  are  paralysis  of  the  extensors  of  the  knee  with 
wastuig  of  the  muscles,  anesthesia  of  the  anterolateral  parts  of  the 
thigh,  and  of  the  umer  side  of  the  leg  to  the  big  toe.  This  nerve  is 
sometimes  involved  early  in  growths  about  the  spine,  and  there  may  be 
pain  in  its  area  of  distribution.  Loss  of  the  power  of  abducting  the 
thigh  results  from  paralysis  of  the  gluteal  nerve,  which  is  distributed 
to  the  gluteus  medius  and  minimus  muscles. 

* 'External  Cutaneous  Nerve. — A  pecuUar  form  of  sensory  disturb- 
ance, confined  to  the  territory  of  this  nerve,  was  first  described  by 
Bernhardt  in  1895,  and  a  few  months  later  by  Roth,  who  gave  it  the 
name  of  meralgia  parcesthetica.  The  disease  is  probably  due  to  a 
neuritis  which  seems  to  originate  in  that  part  of  the  nerve  where  it 
passes  under  Poupart's  Hgament,  just  internal  to  the  anterior  superior 
iHac  spine.  The  nerve  is  usually  tender  on  pressure  at  this  point. 
The  disease  is  more  common  in  men.  Musser  and  Sailer  in  1900 
collected  99  cases,  of  which  75  were  in  men.  A  large  number  of  the 
cases  are  attributable  to  direct  traumatism  or  to  simple  pressure  on  the 
nerve  by  the  aponeurotic  canal  through  which  it  passes.  Pregnancy 
is  among  the  more  common  causes  in  women.  The  sensory  disturb- 
ances consist  of  various  forms  of  paresthesia  located  over  the  outer  side 
of  the  thigh,  oftentimes  with  some  actual  diminution  in  the  acuity  of 
sense  perception.  The  symptoms,  in  varying  intensity,  may  persist 
for  years,  and  the  discomfort  in  some  cases  be  so  great  and  so  much 
exaggerated  even  by  the  mere  touch  of  the  clothing  that  patients  may 
be  greatly  incapacitated  thereby.  Excision  of  the  nerve  as  it  passes 
under  Poupart's  hgament  has  given  good  results. 

"Sacral  Plexus. — The  sacral  plexus  is  frequently  involved  in  tumors 
and  inflammations  within  the  pelvis  and  may  be  injured  during  parturi- 
tion.    Neuritis  is  common,  usually  an  extension  from  the  sciatic  nerve. 

"Goldthwait  calls  attention  to  the  fact  that  the  lumbosacral  artic- 
ulation varies  greatly  in  its  stabihty,  and  actual  displacement  of  the 
bones  may  result,  with  separation  of  the  posterior  portion  of  the  inter- 
vertebral disk.  The  cauda  equina,  or  the  nerve-roots,  may  be  com- 
pressed. With  displacement  on  one  side  the  spine  is  rotated  and  the 
articular  process  of  the  fifth  is  drawn  into  the  spinal  canal,  with  such 


SCIATICA 


577 


narrowing  that  paraplegia  may  result,  and  he  reports  a  remarkable 
case  in  which  the  paralysis  came  on  during  the  appHcation  of  a  plaster 
jacket.  Weakness  of  the  joints  or  the  partial  displacements  may  cause 
irritation  of  the  nerves  inside  and  outside  the  canal  with  resulting 
bilateral  sciatica. 

"Of  the  branches,  the  sciatic  nerve,  when  injured  at  or  near  the 
notch,  causes  paralysis  of  the  flexors  of  the  legs  and  the  muscles  below 
the  knee,  but  injury  below  the  middle  of  the  thigh  involves  only  the 
latter  muscles.  There  is  also  anesthesia  of  the  outer  half  of  the  leg, 
the  sole,  and  the  greater  portion  of  the  dorsum  of  the  foot.  Wasting 
of  the  muscles  frequently  follows,  and  there  may  be  trophic  disturb- 
ances. In  paralysis  of  one  sciatic  the  leg  is  fixed  at  the  knee  by  the 
action  of  the  quadriceps  extensor  and  the  patient  is  able  to  walk. 

"Paralysis  of  the  small  sciatic  nerve  is  rarely  seen.  The  gluteus 
maximus  is  involved,  and  there  may  be  difl&culty  in  rising  from  a  seat. 
There  is  a  strip  of  anesthesia  along  the  back  of  the  middle  third  of  the 
thigh. 

"External  Popliteal  Nerve. — Paralysis  involves  the  peronei,  the 
long  extensor  of  the  toes,  tibiaUs  anticus,  and  the  extensor  bre\ds  digi- 
torum.  The  ankle  cannot  be  flexed,  resulting  in  a  condition  known  as 
*foot-drop,  and,  as  the  toes  cannot  be  raised,  the  whole  leg  must  be 
lifted,  producing  the  characteristic  steppage  gait  seen  in  so  many  forms 
of  peripheral  neuritis.  In  long-standing  cases  the  foot  is  permanently 
extended,  and  there  is  wasting  of  the  anterior  tibial  and  peroneal 
muscles.  The  loss  of  sensation  is  in  the  outer  half  of  the  front  of  the 
leg  and  on  the  dorsum  of  the  foot. 

"Internal  Popliteal  Nerve. — When  paralyzed,  plantar  flexion  of 
the  foot  aiid  flexion  of  the  toes  are  impossible.  The  foot  cannot  be 
adducted,  nor  can  the  patient  rise  on  tiptoe.  In  long-standing  cases 
talipes  calcaneus  follows,  and  the  toes  assume  a  claw-Hke  position 
from  secondary  contracture,  due  to  overextension  of  the  proximal 
and  flexion  of  the  second  and  third  phalanges"  (Osier). 

SCIATICA 

This  is  commonly  a  very  painful  and  obstinate  affection,  which 
may  last  for  years,  and  apt  to  recur  upon  a  return  of  its  exciting  causes. 
The  first  question  to  settle  is  whether  its  cause  is  intrapehdc,  or  due  to 
inflammation  of  the  nerve  itself  after  its  exit  from  the  sciatic  notch. 
Thus,  it  may  be  occasioned  by  the  disease  of  the  spinal  column,  as  in  a 
severe  case  of  my  own,  which  presented  all  of  the  symptoms  of  extra- 
pelvic  sciatica,  but  which  was  finally  relieved  by  the  appearance  of  a 


578  CLINICAL  MEDICINE 

psoas  abscess  in  the  groin,  proving  that  it  originated  from  a  tuberculous 
vertebra. 

Among  the  commonest  intrapelvic  causes  are  chronic  fecal  accumu- 
lations in  the  descending  colon,  and  I  have  often  caused  great  rehef 
by  the  administration  of  pills  containing  i  drop  of  croton  oil  in  4  gr. 
of  bismuth,  given  at  night. 

In  all  cases  of  sciatica  great  attention  should  be  paid  to  the  state  of 
the  portal  circulation,  and  many  patients  with  this  complaint  are 
reheved  by  a  prolonged  visit  to  Kissengen.  It  is  an  interesting  fact 
that  the  Kissengen  water  is  an  almost  exact  reproduction  of  the  con- 
stituents of  the  blood  in  their  due  proportion,  but  minus  its  corpuscles 
and  albuminous  ingredients;  and  a  prolonged  course  of  such  mineral 
waters  has  the  effect  of  unloading  the  portal  circulation  simply  by  an 
excess  of  the  natural  ingredients  of  the  blood,  which  excess  is  gotten 
rid  of  with  no  drain  upon  the  system  at  large.  When  the  trouble  is 
wholly  of  extrapelvic  origin,  its  nature  may  be  settled  by  an  examina- 
tion of  the  course  of  the  nerves  in  the  leg,  when  the  most  painful  point 
on  pressure  may  be  found  at  the  exit  of  the  nerves  at  the  sciatic  notch, 
or  down  its  course  along  the  posterior  aspect  of  the  thigh,  or  in  the 
popHteal  space,  or  in  the  middle  of  the  calf,  where  the  nerve  Hes  between 
two  heads  of  the  soleus  muscle.  If  the  whole  nerve  trunk  is  involved, 
pressure  may  be  painful  behind  the  external  malleolus. 

A  severe  case  in  my  practice  was  that  of  a  truck  driver,  who  sat  upon 
a  small  seat  above  his  cart,  which,  on  going  over  a  log  in  the  road, 
caused  him  to  be  thrown  up  so  that  he  came  down  with  much  force 
upon  his  seat,  and,  I  have  no  doubt,  thus  ruptured  a  vein  within  the 
sheath  of  the  nerve. 

Sciatica  occurs  particularly  in  men  who  are  exposed  to  cold  or  to 
getting  wet,  and  here  it  is  important  to  settle  whether  the  cause  is 
simply  a  rheumatic  inflammation  of  the  sheath  of  the  nerve  or  whether 
it  be  due  to  an  actual  neuritis'of  the  nerve  trunk;  in  that  case  the  whole 
limb  may  feel  cold,  be  stiffened,  and  its  muscles  atrophied. 

Symptoms. — The  symptoms  of  sciatica  differ  somewhat  according 
to  their  causes.  Necessarily,  pain  is  aggravated  by  every  movement  of 
the  leg,  and  in  walking,  when  the  movements  are  slow  and  the  steps 
very  short.  The  rule  also  is  that  the  pains  are  more  severe  at  night 
and  not  uncommonly  paroxysmal,  interfering  with  sleep,  and  may  be 
so  aggravated  that  strong  men  cannot  avoid  tears. 

Treatment. — When  the  affection  is  due  to  a  rheumatic  inflammation 
of  its  sheath,  it  may  be  relieved  by  free  administration  of  salicylates,  but 
if  the  disease  has  already  become  a  neuritis,  these  remedies  are  insuffl- 


HERPES    ZOSTER  579 

cient.  Entire  rest  of  the  leg  may  then  cure  the  patient  by  his  going 
to  bed  and  strapping  the  whole  limb  to  a  splint.  Hydrotherapy  is 
often  very  beneficial.  The  whole  leg  should  be  douched  with  hot 
water  for  fifteen  minutes  at  a  time,  and  then  a  hypodermic  of  cocain 
administered  in  doses  of  J  to  \  gr.  I  have  often  supplemented  this 
in  chronic  cases  by  the  application  of  the  actual  cautery  along  the 
course  of  the  nerves.  This  should  be  done  only  in  one  way,  which 
is,  to  use  an  ordinary  glass  tube  whose  tip  has  been  reddened  in  a  flame 
of  an  alcohol  lamp  and  then  suddenly  applied  to  the  skin.  When 
thus  properly  heated  the  epidermis  snaps  at  the  application,  which 
should  now  be  instantly  withdrawn,  and,  if  done  properly,  this  leaves 
no  sore  behind.  Much  the  most  effective  procedure,  however,  in  my 
hands  has  been  the  introduction  of  the  whole  limb  into  what  is  called 
the  hot-air  box,  which  contains  superheated  dry  air  raised  to  300°  F., 
each  sitting  occupying  about  twenty  minutes,  once  or  twice  a  day. 

HERPES  ZOSTER 

This  complaint,  commonly  called  shingles,  is  due  to  a  lesion  limited 
to  the  extraspinal  ganghon  on  the  posterior  root  of  a  spinal  nerve  which 
belongs  to  the  sympathetic  nervous  system.  The  lesion  in  the  ganglion 
is  conrmonly  found  to  be  a  hemorrhage  into  the  substance  of  the  gan- 
glion, but  in  other  cases  is  the  result  of  a  disorganizing  inflammation; 
in  either  case  its  origin  or  cause  is  yet  unknown.  The  results  also  are 
characteristically  limited  to  the  cutaneous  distribution  of  the  nerve 
affection;  so  limited  are  its  manifestations  that  they  afford  valuable 
evidence  of  the  anatomic  distribution  on  the  skin  of  the  branches  of 
the  affected  nerve.  Hence,  Dr.  Head  has  been  able  to  demonstrate 
by  them  tfiat  the  area  of  the  distribution  of  these  nerves  is  according 
to  segments,  rather  than  by  single  or  individual  tracts  of  a  spinal 
nerve.  This  distribution  is  demonstrable  by  cutaneous  eruption, 
which  is  altogether  different  from  that  of  any  skin  disease,  and  consists 
at  first  of  a  well-defined  erythema,  whose  surface  in  a  short  time  be- 
comes covered  with  discrete,  but  closely  contiguous  vesicles.  These 
vesicles  at  first  contain  a  clear  hquid.  They  are  not  umbilicated,  like 
the  vesicles  of  small-pox,  but,  like  them,  may  become  filled  with  the 
pyogenic  organisms  of  the  skin,  which  may  give  rise  to  ulcers  at  their 
base,  and  may  leave  scars  to  mark  their  situation.  The  peculiarity, 
however,  of  this  eruption  is  that  it  never  crosses  the  middle  line  of  the 
body  in  front  so  as  to  appear  on  both  sides. 

Previous,  however,  to  the  appearance  of  the  eruption  the  patient 
always  has  special  premonitory  symptoms.     These  consist  of  a  slight 


58o  CLINICAL  MEDICINE 

degree  of  fever,  with  very  pronounced  pain,  limited  to  the  distribution 
of  the  affected  nerve.  Thus,  I  have  known  of  patients  coming  for  con- 
sultation on  account  of  the  pain  alone,  referred  by  them  to  a  single  re- 
gion in  the  back,  and  on  being  surprised,  when  the  physician  has  had 
them  stripped,  to  find  the  characteristic  vesicular  eruption  there. 
Usually  the  pain  accompanied  by  feelings  of  general  malaise  precedes 
the  appearance  of  the  vesicles  by  three  or  four  days. 

When  the  eruption  appears  on  the  trunk  of  the  body  there  is  Httle 
difficulty  in  recognizing  its  relations  to  ganglion  of  the  posterior  root, 
but  is  otherwise  when  the  gangHon  affected  belongs  to  one  of  the 
cranial  nerves.  Thus,  the  sympathetic  ganglion,  called  the  Gasserian 
ganghon,  which  belongs  to  the  third  or  sensory  division  of  the  tri- 
geminus, may  be  affected,  causing  the  eruption  to  appear  first  on  the 
face  near  the  eye,  and  which  may  extend  to  the  eye  itself,  with  the 
most  serious  results  sometimes  to  that  organ,  for  not  only  may  the 
conjunctiva  become  impHcated,  but  the  cornea  also  may  ulcerate,  with 
further  extension  to  the  deeper  parts.  In  some  cases,  however,  the 
inflammation  only  causes  adhesion  of  the  iris  to  the  anterior  chamber. 

The  area  occupied  by  the  rash  is  either  a  part  or  the  whole  of  the 
distribution  of  the  ophthalmic  division.  It  may  extend  as  far  back 
as  the  parietal  eminence,  and  occupy  the  whole  upper  lid  and  side  of 
the  nose  as  far  as  the  ala  nasi.  This  implication  of  the  side  of  the  nose 
is  an  extremely  important  feature,  for,  as  Sir  Joseph  Hutchinson  first 
pointed  out,  the  patients  in  whom  this  area  of  the  skin  is  affected  are 
peculiarly  liable  to  suffer  from  ulceration  of  the  cornea. 

The  pain  which  accompanies  this  localized  affection  is  usually  very 
severe,  and  hence  the  importance  of  the  early  diagnosis  of  the  nature 
of  the  few  vesicles  which  then  appear  about  the  external  canthus  of  the 
eye,  because  to  arrest  the  progress  of  the  disease  when  it  threatens  such 
an  important  organ  as  the  eye  is  imperative.  This  may  be  done  by  the 
administration  of  dram  doses  of  the  fluidextract  of  ergot,  which  I  usu- 
ally prescribe,  combined  with  a  dram  of  elixir  of  cinchona,  to  cause  the 
medicine  to  be  more  acceptable  to  the  stomach. 

This  affection  may  also  be  quite  pronounced  in  other  regions  be- 
sides those  already  detailed.  In  my  own  case  I  was  once  severely 
affected  by  pain  referred  to  the  sacrum,  followed  by  the  eruption  on 
the  inner  aspect  of  the  thigh.  The  rule  is,  that  though  it  may  occur 
at  any  period  of  life,  even  in  infants,  it  may  be  especially  severe  in 
the  case  of  the  aged,  and  leave  them  victims  of  severe  neuralgic  pains 
for  many  months.  In  an  aged  person  these  pains,  of  a  darting  or  aching 
character,  are  apt  to  become  very  chronic.     After  the  rash  has  died 


MYELITIS  581 

away  the  area  of  the  affected  skin  not  infrequently  remains  abnormally 
tender  to  painful  stimuli,  such  as  the  point  of  a  pin  dragged  lightly 
across  it. 

Treatment. — It  is  noteworthy  how  common  this  affection  is.  I 
have  found,  for  the  severe  pains  of  the  acute  stage,  that  nothing 
equals  the  administration  of  the  fluidextract  of  ergot,  as  above  men- 
tioned. For  the  chronic  neuralgias  following  the  attack,  especially  in 
aged  persons,  I  would  use  nitrate  of  silver  in  |-gr.  doses  for  a  week, 
which  may  be  intermitted  when  the  pain  subsides,  but  if  they  become 
at  all  severe,  the  ergot  should  be  resumed,  and  meanwhile  every  meas- 
ure for  improving  the  general  health  adopted,  such  as  iron  with  the 
syrup  of  the  hypophosphites. 

LANDRY'S  PARALYSIS 

I  have  seen  only  one  case  of  this  remarkable  disease.  The  patient 
was  a  man  much  addicted  to  hearty  eating.  Going  into  a  restaurant 
after  being  at  a  theater,  he  partook  freely  of  Russian  caviar.  The  next 
morning  I  went  to  see  him  for  paralytic  symptoms  in  both  feet.  He 
had  no  pains  whatever,  but  a  rapidly  ascending  paralysis  of  first  his 
legs,  then  his  arms,  and  then  of  the  diaphragm.  There  was  no  affec- 
tion at  all  of  the  sphincters.  Death  occurred  in  two  days  from  respi- 
ratory paralysis. 

MYELITIS 

Myelitis,  or  inflammation  of  the  substance  of  the  spinal  cord,  is 
nearly  always  secondary  to  infection,  but  cases  are  reported  as  the 
result  of  direct  injury,  such  as  by  blows  or  railway  accidents.  In 
other  cases  exposure  to  cold  may  be  the  cause  in  a  similar  way  to 
that  whicn  we  have  described  as  the  origin  of  poliomyelitis.  Some 
cases  undoubtedly  have  followed  an  overexertion,  as  among  soldiers 
on  long  marches.  Hemorrhages  into  the  cord  may  also  set  up  local- 
ized patches  of  myelitis.  In  other  cases  chronic  endarteritis,  causing 
ischemia,  may  lead  to  complete  degeneration  of  the  nerve  tissue  of  the 
cord,  as  also  may  arteritis  obliterans  due  to  syphilis.  With  an  affection 
of  such  various  origins  these  differentiations  of  its  forms  may  be  diffi- 
cult, while  the  symptoms,  on  the  other  hand,  are  more  easily  described. 
Thus,  a  transverse  myelitis  may  occur  at  various  definite  levels,  with 
the  symptoms  above  referred  to,  of  a  cord  or  band  across  the  body. 
Examination  may  then  show  an  entire  loss  both  of  sensation  and  of 
motion  in  parts  below,  while  at  the  zone  of  the  sense  of  constriction 
there  is  just  above  it  a  hyperesthetic  area  in  which  sensations  of  pain 
may  be  elicited  more  readily  than  in  health. 


582  CLINICAL  MEDICINE 

The  first  sjrmptoms  of  myelitis  may  consist  of  numbness  and  ting- 
ling, especially  in  the  lower  extremities.  Shortly  afterward  difficulty 
in  micturition  and  then  of  emptying  the  rectum  may  set  in.  Thus, 
after  injuries  to  the  spine  it  is  necessary  to  watch  the  condition  of  these 
organs,  for  not  only  may  complete  retention  occur,  but  it  is  almost 
impossible  to  prevent  inflammation  of  the  bladder,  following  intro- 
duction of  the  catheter,  by  micro-organisms  being  introduced  with 
this  instrument.  It  is  sometimes  impossible  to  prevent  infection  in 
this  way,  because  the  urethra  always  abounds  with  septic  organisms. 
The  catheters,  nevertheless,  should  be  sterilized  by  immersion  in  a  dram 
of  carbolic  acid  to  a  pint  of  water.  Another  serious  condition  is  the 
tendency  to  form  bed-sores  on  the  back.  The  back  should  be  examined 
twice  a  day  for  the  first  signs  of  this  compHcation.  The  skin  of  the 
back  should  be  carefully  bathed  with  a  solution  of  10  gr.  of  alum  in  4 
oz.  of  water,  and  pressure  should  be  prevented  by  india-rubber  rings 
which  are  sold  for  the  purpose.  I  have  found  cotton-batting,  read- 
justed twice  a  day,  very  serviceable  in  such  cases.  It  is  really  incum- 
bent to  change  the  patient  often  from  lying  on  his  back  to  lying  on  his 
side,  and  in  bad  cases  this  should  be  at  least  once  an  hour,  for  a  bed- 
sore, once  formed,  is  very  difficult  to  heal,  and  these  easily  become 
gangrenous,  not  uncommonly  penetrating  in  their  course  to  the  spinal 
cord  itself. 

The  best  application  I  have  found  is  an  ointment  composed  of  i 
dram  of  tannate  of  lead  to  i  oz.  of  simple  cerate,  with  the  addition 
of  3  to  4  gr.  of  salicylic  acid. 

POTT'S  DISEASE 

This  may  be  either  easy  or  quite  difficult  to  diagnose,  because  its 
symptoms  are  necessarily  so  varied.  Thus,  I  was  called  to  see  a  child 
who  had  been  treated  for  worms  because  it  complained  of  pain  at  the  pit 
of  the  stomach.  Not  finding  any  rigidity  of  the  muscles  there,  I  turned 
it  over  to  examine  its  spine,  and  found  that  one  of  the  dorsal  vertebra 
was  quite  tender  to  pressure,  due  to  tubercular  caries,  without  as  yet 
any  deformity.  The  first  symptom  in  these  may  be  only  pain  upon 
jarring  the  spine  in  descending  stairs.  A  fixed  pain  in  the  back, 
whether  in  a  child  or  in  an  adult,  should  always  excite  our  suspicions 
and  call  for  a  searching  examination.  Tuberculous  disease  of  a  ver- 
tebra is  the  commonest  cause  of  spinal  symptoms,  though  such  symp- 
toms may  occur  without  the  vertebra  itself  being  diseased.  Thus, 
such  symptoms,  if  they  occur  suddenly  with  much  pain,  may  be  due  to 
hemorrhage  within  the  spinal  canal,  but  this  is  not  common.     The  more 


NEUlilTIS  583 

usual  cause  is  from  tuberculous  infiltration  of  the  membranes,  particu- 
larly if  subdural.  But,  however  occasioned,  pressure  upon  the  nerves 
issuing  from  the  spinal  canal  will  be  characterized  by  pains  following 
distribution  of  the  implicated  nerves. 

If  the  disease  is  high  up  in  the  neck  the  resulting  paralysis  may  be 
the  most  widespread  ever  seen.  I  had  a  hospital  patient  who  was 
threatened  with  death  from  paralysis  of  every  muscle  below  the 
second  cervical  vertebra.  Suspecting  that  it  was  syphilitic  in  nature, 
he  was  soon  cured  by  intramuscular  injections  of  corrosive  sublimate. 

Vertebral  tubercular  disease  leads  usually  to  kyphosis,  commonly 
called  humpback.  The  spinal  cord  then  becomes  compressed,  produc- 
ing motor  paralysis  of  the  parts  below  the  seat  of  the  disease.  It  is 
very  desirable,  therefore,  to  recognize  the  onset  of  this  complaint 
— called  Pott's  disease,  from  the  surgeon  who  first  described  it — early, 
so  as  to  prevent  the  development  of  the  deformity  by  proper  appli- 
ances. One  of  the  early  symptoms,  either  of  compression  or  actual 
myelitis  itself,  is  what  is  called  a  girdle-pain,  as  if  a  cord  or  band  were 
drawn  tightly  across  the  body.  Not  imcommonly  the  physician  is 
called  when  the  mischief  has  already  happened,  and  all  that  can  be  done 
is  to  diminish  the  after-effects.  If  it  is  a  mid-dorsal  vertebra  which 
is  involved,  contraction  of  the  muscles  of  the  legs  may  occur,  drawing 
the  heels  up  to  the  buttocks.  The  only  treatment  then  is  by  persever- 
ing douches  with  hot  water,  three  times  a  day. 

If  the  lumbar  vertebrae  are  involved  the  sjmiptoms  are  more  serious, 
because  the  sphincters,  both  of  the  bladder  and  of  the  rectum,  are 
affected.  Occasionally  spinal  s3nTiptoms  are  due  to  extension  of  proc- 
esses occurring  outside  the  spinal  canal,  such  as  the  secondary  growth 
from  cancer  or  of  aneurysm  eroding  the  vertebrae,  in  both  cases  often 

producing  agonizing  pain. 

NEURITIS 

This  term  explains  itself — namely,  a  nerve  inflammation — and  may 
be  either  strictly  local  or  very  general.  One  form,  caused  from  a 
stretching  of  nerve-trunks  in  foot-drop,  has  already  been  alluded  to 
in  the  treatment  of  typhoid  fever. 

The  commonest  cause  of  neuritis  is  from  toxemia.  Thus,  it  may 
occur  in  diabetics.  In  them  it  often  begins  as  a  sciatica,  generally 
preceded  by  cramp  in  the  calves  of  the  legs  and  abolition  of  the  knee- 
jerk,  but  I  have  known  diabetic  neuritis  to  be  very  local,  involving  only 
one  nerve  in  the  arm. 

The  most  common  cause,  however,  of  a  general  neuritis  is  from  the 
use  of  alcoholic  stimulants,  usually  coming  on  gradually,  but  some- 


584  CLINICAL  MEDICINE 

times  so  suddenly  that  the  patient  falls  from  paralysis  of  the  legs. 
As  a  rule,  however,  it  is  easily  diagnosed  by  the  presence  of  pains 
elicited  on  pressure  of  the  affected  muscles.  When  these  pains  are 
at  all  general  m  either  the  upper  or  lower  Umbs,  by  handling  the  affected 
muscles  it  is  almost  pathognomonic,  and  is  a  valuable  sign  in  patients 
addicted  to  secret  drinking,  particularly  in  women,  for  they  are  at  least 
four  times  as  subject  to  alcohoUc  neuritis  as  men.  One  of  the  marked 
symptoms  of  these  cases  when  severe  is  a  wrist-drop,  which  differs 
from  that  in  lead-poisoning  by  the  pain  which  accompanies  it,  being 
either  spontaneous  or  elicited  by  pressure.  Not  uncommonly  alco- 
hoKc  neuritis  is  accompanied  by  mental  disturbances  which  may 
amount  to  delirium,  or,  in  other  cases,  to  the  most  varied  hallucina- 
tions, when  the  patients  will  entertain  you  with  accounts  of  purely 
imaginary  events.  Alcoholic  neuritis  does  not  often  involve  the  cra- 
nial nerves,  and  in  this  differs  from  rheumatic  neuritis,  which  is  a  fre- 
quent cause  of  paralysis  of  the  lower  branches  of  the  seventh  facial 
nerve. 

Treatment. — The  chief  remedy  for  alcoholic  neuritis  is  absence  from 
its  cause,  namely,  chronic  alcoholic  drinking.  These  patients,  when 
taxed  with  the  habit,  are  apt  to  deny  it,  because  they  have  not  been 
intoxicated  at  any  one  time.  The  fact  is,  that  drunkards  often  escape 
alcohoHc  neuritis  altogether,  and  it  is  rather  the  slow  and  habitual  in- 
gestion of  the  poison,  particularly  in  women,  which  produces  the 
neuritis.  The  gait  might  be  confounded  with  the  gait  of  locomotor 
ataxia,  but  differs  from  it  in  that  the  tabetic  patient  comes  down 
heavily  upon  the  heel,  and  then  afterward  lets  the  foot  drop  upon 
the  floor.  The  alcoholic  patient,  on  the  other  hand,  Hfts  the  whole 
foot  high  up,  as  if  stepping  over  some  obstacles,  dropping  it  down 
upon  the  ball  of  the  foot.  The  wrist-drop  of  alcoholics  also  differs 
from  that  in  lead-poisoning,  in  that  the  hands  are  very  sensitive  to 
pressure. 

Neuritis  also  occurs  both  in  lead-  and  arsenic-poisoning,  which 
have  already  been  described. 

ANGIONEUROTIC  EDEMA 

This  is  a  name  given  to  an  affection  Umited  to  the  vasomotor 
nerves.  It  is  characterized  by  swelling  occurring  rather  suddenly 
upon  the  skin  resembling  urticaria.  It  may  involve  the  lips  and  the 
eyelids,  and  frequently  comes  out  on  the  anterior  surface  of  the  abdo- 
men.    It  may  or  may  not  be  accompanied  with  severe  itching,  but 


ANGIONEUROTIC   EDEMA  585 

is  often  associated  with  violent  internal  cramps,  and  is  almost  inva- 
riably characterized  by  disturbances  of  digestion.  These  sudden 
swellings  may  be  dangerous  to  Hfe  in  some  situations,  for  2  deaths 
have  been  reported  from  involvement  of  the  larynx.  It  is  a  remarkably 
hereditary  or  family  disease. 

Treatment. — The  best  treatment  for  it  is  by  1 5-gr.  doses  of  calcium 
lactate,  four  times  a  day,  and  by  intestinal  antiseptics,  such  as  sodium 
benzoate  and  sodium  salicylate,  each  10  gr.,  an  hour  after  meals  and  at 
night. 


CHAPTER  XVIII 

DISEASES  OF  THE  CRANIAL  NERVES 

OLFACTORY  NERVES 

The  sense  of  smell  is  relatively  unimportant  in  man  compared  to 
what  it  is  in  the  dog,  for  instance,  where  the  development  of  its  power  is 
astonishing.  In  us  it  is  chiefly  important  in  assisting  the  sense  of  taste, 
for  by  it  alone  we  distinguish  the  different  flavors  of  articles  in  our  food. 
Thus,  I  had  a  deUcate  young  lady  who,  on  account  of  the  loss  of  smell 
from  an  obscure  cause,  could  not  distinguish  between  tea  and  coffee, 
nor  between  the  taste  of  broiled  steak  and  a  piece  of  broiled  ham ;  mean- 
time she  could  distinguish  perfectly  between  non-volatile  articles,  such 
as  the  taste  of  salt  and  that  of  lemon.  This  loss  of  smell  is  famiharly 
known  to  us  when  we  catch  a  cold  in  the  head,  and  in  such  cases  is  then 
due  to  the  swelling  of  the  mucous  membrane;  but  anosmia,  or  loss  of 
the  sense  of  smell,  may  be  due  to  brain  disease,  and  is  then  a  serious 
symptom.  A  gentleman  once  consulted  me  because  he  had  such  dread- 
ful odors  constantly  annoying  him  when  he  was  awake.  In  time  he 
died  from  brain  tumor. 

It  is  also  frequently  reported  as  an  aura  preceding  an  epileptic  fit. 
This  sense,  therefore,  should  be  tested  in  every  case  of  supposed  cere- 
bral disease,  when  the  examiner  may  find  that  its  absence  is  the  only 
symptom  of  serious  organic  change  in  the  brain.  In  making  such  tests, 
however,  no  irritant  agents,  such  as  ammonia,  should  be  tried,  because 
they  would  affect  the  branches  of  the  fifth  nerve  and  have  nothing  to 
do  with  the  olfactory  nerve. 

THE  OPTIC  NERVE  AND  TRACT 

We  have  already  spoken  of  the  retina  as  an  outlying  department  of 
the  brain  itself,  from  whose  cells  the  optic  tract  itself  virtually  begins, 
for  its  axons  degenerate  from  the  retina  up  to  the  primary  centers  of 
vision  when  the  eye  is  enucleated  or  otherwise  destroyed.  The  retina 
is  an  extremely  complex  structure,  consisting  of  no  less  than  ten  layers 
of  cells;  the  more  sensitive  part  to  sight  and,  therefore,  the  most  di- 
rectly connected  with  vision  is  the  spot  on  the  retina  called  fovea  cen- 
traHs.     The  course,  then,  of  the  optic  nerve  is  much  the  most  complex 

586 


THE    OPTIC   NERVE    AND    TRACT  587 

in  the  body,  its  fibers  leading  from  the  retina  to  the  optic  chiasm,  where 
an  intricate  decussation  of  the  fibers  from  the  two  eyes  takes  place. 
In  the  chiasm  half  of  the  fibers  in  each  optic  nerve  directly  decussate. 
In  the  lower  animals,  such  as  fishes,  amphibia,  and  birds,  the  decussa- 
tion of  fibers  in  the  chiasm  is  complete;  but  in  the  higher  animals,  such 
as  in  the  mammaha  and  notably  in  man,  many  of  the  fibers  do  not 
decussate,  but  continue  on  the  same  side,  while  some  fibers  pass  from 
one  optic  tract  to  another,  probably  to  subserve  binocular  vision. 
After  leaving  the  chiasm,  the  fibers  of  the  optic  tract  make  important 
connections  with  the  lateral  geniculate  bodies,  so  that  by  many  these 
geniculate  bodies  are  considered  to  be  the  primary  seats  of  vision. 
From  the  geniculate  bodies  a  new  set  of  neurons  begin,  which  ter- 
minate in  the  convolution  called  the  cuneus,  along  what  is  called  the 
calcarine  fissure,  thus  constituting  the  final  cortical  center  of  vision. 
But  on  the  way  from  the  geniculate  bodies  some  fibers  connect  with 
the  superior  corpora  quadrigemina,  while  others  join  the  puhdnar  por- 
tion of  the  optic  thalamus,  the  thalamus  being  itself  the  great  center  in 
the  brain  for  sensation. 

Due  to  the  distribution  of  the  nerves,  as  above  described,  circum- 
scribed lesion  in  one  hemisphere  may  cause  a  person  to  see  only  half 
of  an  object,  to  which  defect  the  term  ''hemiopia"  has  been  given. 
This  was  first  correctly  defined  in  its  nature  by  the  celebrated  English 
scientist,  Wollaston,  who  detected  it  in  his  own  eye  while  riding  in  a  cab. 

There  are  other  ocular  defects  the  result  of  organic  changes  that 
are  described;  some  of  these  consist  of  diminution  of  the  area  of  vision 
in  the  retina.  Besides  these,  we  have  the  striking  condition  called  color- 
blindness. Derangements  in  this  are  nearly  always  congenital.  Thus, 
I  had  a  gentleman  who  never  saw  the  color  red,  while  his  wife,  on  the 
contrary,  was  so  fond  of  the  color  that  both  in  dress  and  in  house  orna- 
ments she  would  choose  nothing  but  red.  In  her  case  I  found  she  could 
not  distinguish  yellow  from  green.  These  defects  in  the  color  sense 
lead  to  sailors  and  railroad  men  having  their  color  sense  tested  before 
they  are  engaged,  because  serious  consequences  may  be  entailed  by 
their  faulty  perception  of  color  in  their  business. 

We  have  refrained  from  dealing  with  the  subject  of  the  treatment 
of  derangements  of  vision,  because  the  eye  is  such  a  dehcate  organ  that, 
like  the  ear,  its  disorders  should  be  treated  by  specialists. 

Albuminuric  Retinitis 

Disturbances  of  vision,  when  due  to  organic  changes  in  the  optic 
tracts,  may  be  either  peripheral,  so  to  speak,  or  centric.     When  per- 


588  CLINICAL   MEDICINE 

ipheral,  its  changes  are  in  the  retina  itself,  and,  of  course,  can  only 
be  recognized  by  the  ophthalmoscope.  The  commonest  form  of  such 
changes  is  albuminuric  retinitis,  and  very  often  is  the  first  sign  of 
interstitial  nephritis.  Patients  may  consult  physicians  for  dimness 
of  vision,  little  expecting  the  verdict  of  the  examiner  that  they  are 
already  far  advanced  in  serious  kidney  disease.  The  changes  in  the 
retina  in  this  affection  may  either  be  degenerative  or  actually  inflam- 
matory. The  degenerative  forms  are  characterized  by  thickening  and 
tortuosity  of  the  blood-vessels  of  the  retina,  along  with  minute  retinal 
hemorrhages  and  white  patches  following  the  course  of  the  vessels. 
Such  appearances  are  far  more  common  in  cases  of  chronic  interstitial 
nephritis,  accompanied  by  general  arteriosclerosis  and  high  tension  of 
the  pulse.  They  may  occur,  however,  in  parenchymatous  nephritis, 
but  are  relatively  uncommon. 

The  seriousness  of  this  condition  of  the  retina  may  be  judged  by 
the  fact  that  most  of  such  patients  do  not  live  a  year  from  the  time 
of  its  detection.  If,  however,  the  retinal  hemorrhage  is  at  the  begin- 
ning so  profuse  as  to  destroy  for  a  time  the  sight,  the  prognosis  is  not 
so  imfavorable.  I  have  a  patient  in  which  this  actually  occurred,  and 
he  told  me  that  he  had  a  brother  who  died  from  chronic  B  right's  dis- 
ease, but  he  soon  recovered  his  sight,  and  is  now  Hving,  three  years 
afterward,  in  apparent  good  health. 

Retinitis  also  occurs  as  a  part  of  impoverished  condition  of  the 
blood  from  any  cause.  It  is  common,  for  example,  in  pernicious  ane- 
mia, and  is  also  met  with  in  leukemia.  It  is  not  uncommon  in  tabes,, 
although  more  frequently  it  is  then  preceded  or  accompanied  by  cho- 
roiditis. 

Optic  Neuritis 

Inflammation  of  the  optic  nerve  itself  may  occur,  but  oftener  we 
have  a  combination  of  both  neuritis  and  retinitis.  The  retina  may  be 
studded  with  hemorrhagic  spots,  red  if  recent,  or  black  if  chronic. 

One  form  is  of  much  interest  when  it  is  associated  with  the  presence 
of  a  growing  tumor  in  the  brain  substance.  Usually  a  disturbance  of 
vision  is  preceded  in  these  cases  by  headache  and  vomiting.  On  oph- 
thalmoscopic examination  the  condition  termed  "choked  disk"  may 
be  found.  It  is  in  such  cases  that  trephining  the  skull  for  the  relief  of 
intercranial  pressure,  which  though  only  palliative,  may  afford  great 

relief. 

Optic  Atrophy 

Much  the  commonest  cause  of  primary  optic  atrophy  is  tabes,  al- 
ready referred  to  in  the  article  on  that  disease,  and,  as  there  mentioned, 


THE    TRIGEMINUS,    OR   FIFTH   NERVE  589 

it  is  curious  that  the  other  symptoms  of  locomotor  ataxia  may  be  but 
little  pronounced,  while  the  blindness  is  total.  A  patient  was  once 
referred  to  me  by  a  distinguished  oculist,  who,  while  totally  blind  from 
optic  atrophy,  yet  showed  very  little  ataxia  in  any  of  his  bodily  move- 
ments. The  outlook  in  such  cases  is  hopeless.  The  other  causes  that 
have  been  assigned  for  optic  atrophy,  such  as  diabetes  and  lead-poison- 
ing, are  chiefly  hypothetic. 

"The  ophthalmoscopic  appearances  are  different  in  the  cases  of 
primary  and  secondary  atrophy.  In  the  former  the  disk  has  a  gray 
tint,  the  edges  are  well  defined,  and  the  arteries  look  almost  natural; 
whereas,  in  the  consecutive  atrophy  the  disk  has  a  staring  opaque- 
white  aspect  with  irregular  outlines,  and  the  arteries  are  very  small" 
(Osier). 

In  many  cases  the  onset  is  gradual,  consisting  in  progressive  failure, 
both  in  the  acuity  of  vision  and  in  the  range  of  the  visual  field,  as  well 
as  in  the  onset  of  color-blindness. 

As  to  the  other  defects  of  vision,  the  eye  is  such  a  complex  and 
delicate  organ  that  its  treatment  should  be  referred  to  specialists. 

THE  TRIGEMINUS,   OR  FIFTH  NERVE 

The  trigeminus,  or  fifth  nerve,  as  is  well  known,  is  a  mixed  nerve, 
two  of  its  branches  being  sensory  and  one  motor.  A  primary  affection 
of  the  sensory  branches  without  neuritis  is  imcommon.  I  have  seen 
only  one  case  of  it  in  a  young  woman  who  had  total  loss  of  sensation 
in  half  the  face,  and  similarly  within  the  buccal  cavity;  other  than  this 
complete  anesthesia  she  had  no  other  symptoms  whatever,  and  particu- 
larly no  pain.  It  appeared  to  have  come  on  suddenly  without  any 
known  cause.  It  is  well  to  be  careful,  in  affections  of  the  sensory 
branches  of  this  nerve,  to  note  the  conditions  of  the  mucous  membranes 
whose  innervation  is  involved.  Thus,  not  only  is  the  conjunctiva  on 
that  side  liable  to  be  inflamed  from  want  of  the  protective  act  of 
winking,  in  removing  dust  or  other  irritating  particles  from  the  eye, 
but  serious  ulceration  of  the  cornea  may  take  place.  The  mucous 
membrane  of  the  nose  is  also  dry,  and  thus  abolishes  the  perception 
of  volatile  flavors,  but  the  sense  of  taste  itself  may  be  diminished,  owing 
to  dryness  of  half  the  surface  of  the  tongue.  I  have  found  it  partic- 
ularly necessary  in  such  cases  to  watch  against  the  development  of 
herpes,  which,  besides  attacking  the  eye,  may  also  produce  the  most 
acute  pain.  For  the  treatment  of  this  pain,  and  for  the  arrest  of  the 
ulceration,  we  have  a  specific  in  the  fluidextract  of  ergot,  for  which  a 
dram  should  be  given  every  three  hours. 


59° 


CLINICAL  MEDICINE 


Paralysis  of  the  muscles  supplied  by  the  motor  portion  of  the  tri- 
geminus— namely,  the  temporal  and  masseter  muscles  used  in  mastica- 
tion— are  rare,  but  tonic  spasm  of  these  muscles,  causing  trismus  or 
lockjaw,  are  too  famiUarly  known  as  invariable  in  tetanus;  occasionally 
they  occur  in  tetany,  as  already  described.  Temporary  trismus  is  not 
infrequent  in  hysteria. 

Trigeminal  Neuralgia 

In  our  chapter  on  Pain  we  showed  in  what  respect  a  neuralgic 
pain  differs  from  all  other  pains,  in  that  it  does  not  have  the  charac- 
teristics of  either  inflammatory,  pressure,  or  of  stretching  pains, 
and  is  best  exempHfied  by  the  degenerative  pains,  Hke  those  so- 
called  Hghtning  pains  of  tabes.  But,  in  actual  pathology,  it  is  not  easy 
to  draw  a  hard-and-fast  line,  for  in  some  pains,  ordinarily  called  neu- 
ralgic, a  true  inflammatory  element  is  often  present.  Tliis  is  true  of 
what  is  called  trigeminal  neuralgia  or  tic  douloureux  of  the  face. 
Thus,  in  the  case  of  tabes,  its  violent  shooting  pains  are  not  aggravated 
by  movement  of  the  part,  nor  are  the  nerves  tender  on  pressure.  In 
trigeminal  neuralgia,  on  the  other  hand,  the  patient  often  dares  not 
chew,  and  frequently  abstains  from  eating  altogether  on  account  of 
every  movement  of  the  affected  muscles  of  the  face,  even  talking 
bringing  on  violent  paroxysms  of  pain,  and  yet  he  often  opens  his  mouth 
to  squeeze  the  aching  muscles  of  the  part.  In  fact,  some  pathologists 
claim  that  the  affected  branches  of  trigeminus  are  really  cases  of  local- 
ized peripheral  neuritis. 

In  fully  developed  cases  it  is  doubtful  if  any  nervous  affection  can 
cause  so  much  acute  pain  as  we  meet  here;  its  causes  merit  serious  at- 
tention. Probably  its  most  frequent  origin  is  from  exposure  of  the  face 
to  cold  winds.  Thus,  the  city  of  Edinburgh,  Scotland,  is  noted  for  the 
frequent  occurrence  there  of  this  neuralgia,  particularly  among  per- 
sons not  native  to  that  windy  city. 

Like  other  similar  neuralgias,  its  victims  are  usually  past  middle 
life.  One  should  learn  the  point  of  exit  on  the  face  of  the  three  branches 
of  this  nerve.  The  exit  of  the  superior  branch  is  on  the  frontal  bone, 
near  the  midway,  over  the  orbit  of  the  eye;  the  second,  or  superior 
maxillary  branch,  comes  out  on  the  malar  process  of  the  upper  jaw; 
the  third,  or  dental  branch,  is  midway  between  the  ramus  and  the  chin. 
There  can  be  little  doubt  that,  as  in  other  neuralgias  of  this  class,  some 
conditions  of  arterial  sclerosis  predispose  to  the  affection,  because  the 
majority  of  the  patients  are  past  middle  life.  The  first  onset  is  com- 
monly sudden,  and  often  after  a  prolonged  exposure  of  the  face  to  cold. 


TRIGEMINAL   NEURALGIA  59I 

It  may  last  for  several  days  or  even  weeks,  and  then  subside,  and  the 
patient  may  fancy  that  he  is  permanently  free  from  it,  but  it  is  sure  to 
return,  though  perhaps  not  until  the  following  winter.  The  interval 
between  the  attacks  after  this  becomes  shorter  and  shorter,  until  life 
is  rendered  a  burden  from  the  continuous  and  severe  recurrent  parox- 
ysms. The  pain  is  frequently  a  burning  one.  It  makes  the  patient 
cringe,  it  causes  a  flow  of  tears,  and  in  very  many  cases  a  sharp, 
quick  contraction  of  the  muscles  of  the  face,  a  closing  of  the  eye,  and 
drawing  up  of  the  mouth.  Mental  emotion  also  may  start  the  pain 
with  great  severity;  the  eye  waters,  and  sometimes  the  secretion  of  the 
nose  is  increased. 

The  most  common  form  of  neuralgia  is  the  supra-orbital,  in  which 
the  pain  is  felt  above  the  eye  and  at  the  notch  or  foramen  through 
which  the  supra-orbital  nerve  makes  its  exit  upon  the  forehead,  and 
over  the  forehead  and  in  the  hair,  as  high  as  the  vertex.  In  long-stand- 
ing cases  all  three  trunks  may  be  involved.  Sometimes  the  pain 
radiates  into  the  eyeball,  and  occasionally  pain  in  the  eyeball  is  the 
only  manifestation  of  neuralgia  of  the  supra-orbital  nerve.  When  the 
infra-orbital  branch  is  the  one  which  is  affected,  pain  is  felt  upon  the 
cheek  and  in  the  upper'  teeth,  and  especially  in  the  antrum  and  malar 
bones.  It  may  then  get  as  far  out  as  the  temple  and  the  lobe  of  the 
ear.  When  the  third  or  lower  branch  of  the  nerve  is  affected,  the  pain 
is  felt  upon  the  cheek  and  Hp  and  in  the  lower  teeth,  also  within  the 
mouth,  even  in  the  tongue,  and  in  some  cases  the  tongue  is  the  chief 
seat  of  the  pain. 

Treatment. — There  have  been  numerous  measures  and  different 
drugs  employed  for  the  treatment  of  this  painful  affection,  some  of 
which  are  of  undoubted  efficacy ;  but  I  would  first  refer  to  a  treatment  of 
my  own,  of  which  the  following  is  an  illustrative  case:  A  gentleman 
aged  seventy-four  contracted  trigeminal  neuralgia  two  years  previously 
while  sojourning  in  Edinburgh;  he  consulted  a  number  of  our  most 
eminent  neurologists,  who  recommended  various  remedies  of  repute, 
but  without  benefit;  his  sufferings  were  pitiable  to  witness,  and  were 
particularly  apt  to  recur  whenever  he  attempted  to  chew  anything. 
I  had  him  go  to  bed,  and  be  attended  by  a  day  and  night  nurse,  who 
kept  him  continuously  under  the  effects  of  full  doses  of  laudanum, 
20  drops  every  two  hours  night  and  day,  thus  insuring  that  he  should 
not  at  any  moment  be  out  of  the  in.fluen.ce  of  the  drug;  he  often  begged 
to  have  it  intermitted,  but  this  was  not  done;  at  times  he  was  deh- 
rious,  though  at  no  time  did  he  show  symptoms  of  opium-poison- 
ing.    After   the   end   of   the   week   the  pain  left  him  permanently, 


592  CLINICAL  MEDICINE 

and  he  had  no  return  till  his  death,  when  he  was  eighty-eight  years 
old. 

Some  cases  of  this  complaint  are  supposed  to  be  malarial  in  origin, 
on  account  of  the  marked  periodicity  of  the  attacks,  and  authors 
recommend  that  they  should  be  treated  with  full  doses  of  quinin,  such 
as  30  gr.  at  a  time,  three  hours  before  the  expected  paroxysm,  having 
taken  the  night  before  a  mercurial  purge.  My  own  experience  is 
that  such  attacks  are  often  due  to  influenza,  instead  of  malaria,  but 
in  either  case  I  prefer  that  they  should  be  treated  by  the  fluidextract 
of  ergot  in  teaspoonf  ul  doses,  along  with  a  teaspoonf  ul  of  elixir  cinchona, 
and  taken  either  at  the  paroxysm  or  an  hour  before,  with  the  addition 
of  12  gr.  of  quinin. 

The  patients  naturally  are  anxious  to  find  what  the  possible  cause 
of  their  painful  affection  may  be,  and  I  rarely  have  met  a  case  which 
has  not  had  every  affected  tooth  in  his  head  extracted;  but,  while  the 
condition  of  the  teeth  should  always  be  noted,  yet,  in  my  experience, 
trigeminal  neuralgia  in  any  form  is  not  found  conjoined  with  dental 
disease. 

Two  drugs  are  justly  of  good  repute  in  this  malady.  The  first  is 
aconitia  or  aconitin;  some  care  has  to  be  observed  in  the  use  of  this 
drug,  as  it  is  a  powerful  depressant.  The  best  preparation  of  this 
drug  is  Chapoteaux's  pills,  containing  ytq  gr-,  or  |  mg.,  which  may  be 
given  at  first  once  every  two  hours,  guided  by  the  effect,  which  is 
weakness  of  the  pulse  and  a  marked  sensation  of  tingling  and  of  numb- 
ness in  the  tongue  and  in  the  fingers.  The  patient  meanwhile  should 
not  be  walking  about,  and  should  be  warned  against  any  sudden  mus- 
cular exertion. 

The  second  remedy  is  gelsemin;  this  should  be  given  in  lo-drop 
doses  of  the  tincture  or  the  fluidextract  until  the  physiologic  effects  are 
produced,  which  are  a  drooping  of  the  eyelids  and  a  difficulty  in  open- 
ing them.  If  the  dose  of  10  drops  every  three  hours  does  not  have  any 
effect,  it  may  be  increased  by  i  drop  each  time  until  the  eyehds  droop. 
I  have  found  in  administering  doses  of  this  drug  that  it  also  produces 
a  sense  of  general  prostration,  in  which  case  the  dose  should  be  de- 
creased; but  this  remedy  often  succeeds  when  aconitin  fails. 

In  gouty  cases,  which  in  this  country  are  quite  common,  wine  of 
colchicum  in  5-drop  doses  every  two  hours  may  be  given.  If  it  pro- 
duces loosening  of  the  bowels  it  may  be  decreased  or  not  given  so 
often. 

Of  other  drugs,  the  arsenic  preparation  called  cacodylate  of  soda 
enjoys  some  repute — I  to  |  gr.  three  times  a  day.     It  may  be  used 


PARALYSIS    OF    FACIAL    NERVE  593 

in  conjunction  with  the  remedies  already  mentioned,  or  alone,  care 
being  taken  to  avoid  toxic  effects. 

If  taken  at  the  very  beginning  of  an  attack,  15  gr.  of  antipyrin 
with  I  dram  of  aromatic  spirits  of  ammonia  may  cut  it  short. 

A  number  of  local  remedies  are  recommended,  but  much  the  most 
efficacious  of  them  is  to  rub  the  face  frequently  with  a  menthol  pencil. 
Camphor  and  chloral,  rubbed  together  into  a  paste  and  applied,  have 
been  of  benefit.  In  cold  weather  the  patient's  face  should  always  be 
protected  by  a  layer  of  cotton  batting  and  oiled  silk,  the  cotton  being 
moistened  with  chloroform  liniment.  If  the  patient  has  a  plain  con- 
dition of  arterial  sclerosis  he  should  take  frequent  doses  of  a  solution 
of  nitroglycerin,  J  gr.  in  6  oz.  of  water,  the  dose  being  one  teaspoonful, 
gradually  increased,  until  it  produces  a  sense  of  throbbing  in  the 
temples. 

Meantime  the  condition  of  the  general  health  should  be  carefully 
attended  to,  as  these  patients  are  usually  below  par  in  this  respect. 

Of  the  various  surgical  procedures  which  have  been  attempted  for 
rehef  from  this  complaint,  the  only  one  which  promises  permanent  re- 
lief is  removal  of  the  Gasserian  ganghon.  This  procedure,  however, 
should  never  be  attempted  except  by  a  surgeon  of  proved  abihty  in 
similar  operations. 

PARALYSIS  OF  FACIAL  NERVE 

Much  the  commonest  form  of  facial  paralysis  is  that  named  after 
Bell,  who  first  adequately  described  it,  after  producing  it  experiment- 
ally in  dogs.  The  cause  is  usually  a  neuritis  produced  by  exposure  of 
the  face  to  cold,  where  the  nerve  makes  its  exit  at  the  stylomastoid 
foramen.  Its  symptoms  then  are  very  striking;  the  whole  side  of  the 
face  is  immovable.  In  the  forehead  the  normal  wrinkles  are  obliter- 
ated, the  eyelid  droops,  but  cannot  be  closed,  the  eye  waters.  If  the 
patient  tries  to  smile  the  face  is  at  once  drawn  to  the  opposite  side. 
Owing  to  paralysis  of  the  buccinator  muscles,  food  collects  between  the 
cheek  and  the  teeth,  and  in  drinking  some  of  the  fluid  may  run  out 
of  the  comer  of  the  mouth.  The  paralysis  of  the  nasal  muscles  is  seen 
on  asking  the  patient  to  sniff. 

It  is  important  to  note  whether  in  this  paralysis  the  sense  of  taste 
is  also  affected  on  the  corresponding  side  of  the  tongue.  If  the  sense 
of  taste  is  affected  in  the  anterior  part  of  the  tongue  on  the  affected 
side  it  shows  that,  besides  the  branches  outside  of  the  stylomastoid 
foramen,  the  nerve  is  also  affected  higher  up  in  the  canal,  between  the 
genu  and  the  origin  of  the  chorda  tympani. 
3a 


594 


CLINICAL  MEDICINE 


Treatment. — ^^The  most  effective  treatment  for  this  affection  is 
based  upon  the  fact  that  it  is  really  a  neuritis,  and  counterirritation  by 
a  blister  on  the  mastoid  process  behind  the  ear,  applied  once  a  week, 
is  generally  efficacious.  Meantime,  faradization  can  be  used  to  the 
affected  muscles,  both  poles  being  tipped  with  moistened  sponges;  one 
pole  is  applied  at  the  nape  of  the  neck,  while  the  other  is  passed  over 
the  muscles  of  the  face.  In  the  majority  of  cases  these  measures  amply 
suffice,  while  meantime  potassium  iodid  may  be  taken,  lo  gr.  in  water 
three  times  a  day,  an  hour  after  meals. 

SPASH 

The  muscles  supplied  by  the  seventh  nerve  are  sometimes  strikingly 
affected  by  spasm.  This  is  particularly  the  case  with  blepharospasm, 
or  spasm  of  the  orbicularis  muscle.  This  has  sometimes  been  treated 
by  full  doses  of  the  fluidextract  of  conium,  and  I  knew  of  one  case  in 
which  a  poisonous  dose  of  this  drug  was  given  by  an  ocuHst  with  a 
fatal  result.  I  believe,  however,  that  it  would  be  best  treated  by  the 
fluidextract  of  gelsemium  in  lo-drop  doses,  cautiously  increased  by 
I  drop  with  each  dose,  until  constitutional  effects  are  produced. 
In  some  cases  the  spasm  extends  to  all  branches  of  the  facial  nerve, 
when  the  patient  seems  to  be  making  constant  grimaces. 

Weir  Mitchell  recommends  freezing  of  the  cheek,  for  a  few  min- 
utes daily  or  every  second  day,  with  ethyl  spray,  and  this,  in  some 
instances,  is  beneficial.  I  would  prefer  the  application  of  a  liniment 
composed  of  an  ounce  each  of  the  liniment  of  aconite,  the  liniment  of 
belladonna,  and  the  liniment  of  chloroform,  with  the  addition  of  i 
dram  of  menthol,  this  to  be  applied  on  the  face  and  then  covered  by 
cotton  and  oiled  silk,  three  times  a  day. 

AFFECTIONS  OF  THE  AUDITORY  NERVE 

The  ear,  or  the  organ  of  hearing,  is  divisible  into  three  parts,  whose 
relations  to  one  another  should  be  distinctly  remembered.  The  first 
is  the  pinna,  or  the  external  ear;  the  second  is  the  external  or  auditory 
canal,  which  ends  ia  the  tympanic  cavity;  this  canal  is  about  ij  inches 
in  length,  its  direction  is  obliquely  forward  and  inward,  and  it  is  slightly 
curved  upon  itself.  This  curve  makes  it  a  little  difficult  to  look  through 
the  canal  so  as  to  get  a  view  of  the  tympanum,  but  by  pulUng  up  the 
tragus  the  curve  is  so  altered  that  a  view  of  the  tympanum  can  be 
obtained.  The  office  of  the  pinna  is  to  collect  the  sounds  as  they  come 
from  all  quarters  and  conduct  them  into  the  auditory  canal.  In  man 
the  pinna  is  scarcely  movable,  but  in  many  of  the  mammals,  such  as 


AFFECTIONS    OF   THE    AUDITORY   NERVE  595 

the  equines,  rabbits,  etc.,  it  answers  an  important  purpose  by  its  length 
and  movablHty,  enabling  them  quickly  to  detect  the  direction  of  the 
sounds  much  better  than  we  can. 

The  tympanum  is  an  irregular  cavity,  being  a  Httle  broader  behind 
and  above  than  it  is  below  and  in  front.  It  is  filled  with  air,  as  is  also 
the  Eustachian  tube  which  communicates  with  it.  This  tube  is  from 
i^  to  2  inches  in  length,  with  the  direction  downward,  forward,  and 
inward,  opening  in  the  pharynx  on  a  level  with  the  floor  of  the  posterior 
nares.  On  that  account  no  liquid  injections  should  be  made  into  the 
nose,  for  they  can  pass  directly  into  the  Eustachian  tube  and  set 
up  serious  inflammation  there. 

The  tympanum  is  traversed  by  a  chain  of  httle  movable  bones,  three 
in  number — the  malleus,  incus,  and  stapes — the  latter  so-called  from 
its  exact  resemblance  to  a  stirrup.  The  malleus  is  attached  to  the  mem- 
brana  tympani;  the  stapes,  to  the  fenestra  ovaHs;  the  incus  being  placed 
between  the  two.  The  above-mentioned  structures  form  the  middle 
ear.  The  middle  ear  is  separated  from  the  inner  ear  by  a  membrane 
stretched  across  an  opening  called  the  fenestra  ovahs,  to  which  the 
stapes  is  attached. 

The  inner  ear,  or  the  labyrinth,  begins  at  an  opening  called  the 
fenestra  ovalis.  It  is  called  the  labyrinth  from  the  complexity  of  its 
shape,  and  consists  of  three  parts — the  vestibule,  semicircular  canal,  and 
cochlea.  It  is  formed  by  a  series  of  cavities  chaimeled  out  of  the  sub- 
stance of  the  petrous  bone,  communicating  externally  with  the  cavity 
of  the  tympanum  through  the  fenestra  ovaHs  and  rotunda,  and  inter- 
nally with  the  meatus  auditorius  intemus,  which  contains  the  auditory 
nerve.  Within  the  osseous  labyrinth  is  contained  the  membranous 
labyrinth,  upon  which  the  ramifications  of  the  auditory  nerve  are  dis- 
tributed. 

What  the  old  anatomists  called  the  eighth  or  acoustic  nerve  is  com- 
posed of  two  distinct  nerves  quite  different  in  function.  Thus,  the 
vestibular  nerve  has  nothing  to  do  with  hearing,  and,  instead,  is  distrib- 
uted to  the  semicircular  canals,  whose  business  it  is  to  maintain  the 
equiHbrium  of  the  body.  We  have  already  described  its  functions  in 
our  chapter  on  Vertigo. 

Our  sense  of  hearing,  instead,  depends  upon  the  integrity  of  the 
cochlea,  which  is  an  organ  whose  complexity  is  extraordinary;  nothing, 
in  fact,  is  so  impressive  as  the  minute  structure  and  beautiful  arrange- 
ment of  the  finer  portion  of  this  organ.  The  whole  structure  is  esti- 
mated to  contain  about  24,000  strings,  varying  gradually  in  length,  as 
stated.     Within  the  cochlea,  and  bathed  in  its  lymph,  is  an  apparatus 


596  CLINICAL  MEDICINE 

of  hairs  of  different  lengths.  The  cochlea  itself  resembles  a  spiral 
snail  shell,  whence  its  name.  Suspended  in  the  endolymph  is  the 
basilar  membrane;  on  this  membrane  are  arranged  a  peculiar  class  of 
cells,  called  the  rods  of  Corti,  which  number  about  3000  pairs.  Lying 
against  the  rods  of  Corti  are  certain  other  cells,  called  hair-cells,  which 
terminate  in  small  hair-like  processes.  When  viewed  from  above  the 
organs  of  Corti  show  a  remarkable  resemblance  to  the  keyboard  of  a 
piano. 

The  path  from  the  cochlear  nerve  extends  to  the  brain  cortex  and 
terminates  in  the  temporosphenoidal  gyrus,  which  is  the  cortical  center 
for  hearing.  In  man  this  gyrus  has  centers  differing  in  their  functions: 
one  is  for  the  understanding  of  words;  this  may  be  separately  diseased, 
when  the  person  is  said  to  become  word-deaf.  He  may  be  able  to 
appreciate  all  other  sounds,  but  words  convey  no  meaning  to  him. 
Another  center  close  to  it  is  the  musical  one.  Thus,  cases  are  reported 
of  expert  musicians  becoming  unable  to  tell  one  tune  from  another 
owing  to  damage  to  this  center.  Affections  of  any  part  of  the  ear  which 
we  have  described  may  cause  diminution  or  actual  loss  of  hearing,  and 
hence  should  lead  to  careful  examination  in  any  case  of  deficient 
hearing.  Thus,  the  mere  plugging  of  the  external  auditory  canal  by 
hardened  wax  may  cause  deafness,  the  removal  of  which  may  actually 
alarm  the  patients  from  the  sudden  restoration  of  their  full  appreciation 
of  sounds.  Much  more  common  are  affections  of  hearing  from  inflam- 
mations of  the  middle  ear,  or  otitis  media ;  in  some  of  these  cases  infla- 
tion of  the  Eustachian  tube,  from  its  opening  below  in  the  pharynx, 
may  greatly  benefit  the  hearing.  It  is  from  neglecting  to  attend  to 
otitis  media  that  cases  may  occur  in  scarlet  fever,  which,  beginning 
with  a  sore  throat  of  the  disease,  may  extend  up  the  Eustachian  tube 
and  cause  permanent  deafness.  We  have  already  referred  to  this 
calamity  as  the  frequent  cause  of  deaf -mutism  after  scarlatina. 

Inflammation  at  the  base  of  the  brain  may  involve  the  acoustic 
nerve,  particularly  in  cerebrospinal  meningitis.  I  had  a  case  in  which 
permanent  total  deafness  occurred  from  this  cause  on  the  fifth  day  of 
the  disease.  Actual  loss  of  hearing  may  occur  from  locomotor  ataxia, 
and  also  from  syphilitic  exudation  at  the  base  of  the  brain,  which  may 
or  may  not  be  curable  by  large  doses  of  potassium  iodid.  In  one  person 
of  my  acquaintance  his  trouble  terminated  in  a  series  of  convulsions  in 
which  he  died. 

Deafness  is  also  very  common  from  general  arteriosclerosis  and  in 
the  case  of  progressive  loss  of  hearing  so  common  in  old  age.  The 
S3rmptoms  of  this  condition  are  simply  those  of  increasing  deafness 


AFFECTIONS    OF    THE    AUDITORY    NERVE  597 

without  any  signs  of  pain  or  local  inflammation.  It  is  important,  how- 
ever, to  know  the  cause,  for  in  many  cases  by  dealing  with  the  arterio- 
sclerosis itself,  as  we  have  mentioned  in  the  chapter  on  that  disease,  the 
failing  function  of  hearing  may  be  considerably  medicated. 

In  examination  of  the  ear  the  watch  should  be  first  used  to  note 
the  distance  at  which  its  ticking  can  be  heard  with  both  ears,  for  often 
the  patient  is  surprised  to  find  the  difference  between  one  ear  and  its 
fellow  in  this  respect.  If  the  patient  can  scarcely  hear  the  watch, 
however  close  it  is  brought  to  the  external  meatus,  it  or  a  tuning-fork 
should  be  laid  against  the  mastoid  process.  If  it  is  then  heard  plainly, 
the  trouble  is  not  in  the  auditory  nerve.  Connected  with  the  tympa- 
num are  the  numerous  cells  which  are  found  in  the  mastoid  process 
behind  the  ear,  and  which,  besides  communicating  with  one  another, 
enter  the  cavity  of  the  tympanum  by  one  or  two  openings.  On  account 
of  this  connection,  inflammation  of  the  middle  ear  may  extend  to  the 
mastoid  cells.  In  very  acute  suppuration  of  the  middle  ear  the  mucous 
membrane  of  the  antrum  and  mastoid  cells  is  simultaneously  or  con- 
secutively affected,  there  being  at  first  a  simple  empyema,  and  next, 
especially  in  infective  cases  or  enfeebled  individuals,  impHcation  of  the 
bone  of  the  nature  of  caries,  and  occasionally  necrosis.  This  often 
becomes  infected  by  invasion  of  streptococci,  which,  when  it  occurs, 
necessarily  involves  a  surgical  operation  to  let  pus  out. 

The  symptoms  of  this  condition  are  pain  radiating  over  the  side  of 
the  head  and  tenderness  on  pressure  over  the  mastoid  process,  with 
swelling  of  the  tissues  behind  the  ear;  and,  lastly,  if  this  condition  is  not 
speedily  removed  by  operation,  an  abscess  may  form  in  the  brain  itself 
which  may  soon  terminate  Hfe. 

Tinnitus  aurium,  or  ringing  in  the  ears,  is  a  very  common  affection 
in  persons  past  middle  life.  It  is  due  to  a  number  of  causes,  some  but 
not  many  of  which  are  owing  to  actual  organic  disease;  usually,  how- 
ever, no  cause  can  be  assigned  for  it,  so  that  authors  speak  of  it  as 
merely  subjective.  It  is  never  pleasant  to  the  patient  himself,  so  is 
said  in  some  cases  to  have  actually  led  to  suicide.  My  own  view  is 
that  it  is  generally  caused  by  derangement  of  the  blood;  thus,  loss  of 
blood  or  simple  anemia  may  occasion  it ;  in  other  cases  a  gouty  condi- 
tion is  responsible,  for  in  these  patients  treatment  for  the  gouty  con- 
dition does  the  most  good.  In  the  majority,  however,  arteriosclerosis 
is  the  chief  cause.  For  the  treatment  for  this  troublesome  symptom  I 
have  found  nothing  better  than  free  dosing,  three  times  a  day,  of  15  gr. 
either  of  the  strontium  or  the  ammonium  bromid. 


598  clinical  medicine 

Glossopharyngeal  Nerve 

Derangements  of  the  ninth  (or  glossopharyngeal)  nerve  of  centric 
origin  are  quite  uncommon,  while  peripheral  derangements,  due  to 
changes  in  the  mucous  membrane  of  the  tongue,  are  frequent  in  all 
fevers  when  dryness  of  the  tongue  is  produced.  At  all  times  in  such 
cases  a  wash  of  10  gr.  of  chlorate  of  potash  in  i  oz.  of  water  should  be 
frequently  used  to  prevent  fissures  of  the  tongue.  Occasionally  in 
epilepsy  the  attack  begms  with  an  aura  of  a  perverted  sense  of  taste, 
but  not  so  often  as  a  perversion  of  the  sense  of  smell.  Both  of  these 
disorders  once  occurred  in  a  patient  of  mine,  and  gave  him  great  annoy- 
ance until  he  died  suddenly,  when  a  tumor  was  found  which  involved 
the  origin  of  the  olfactory  nerve. 

PNEUMOGASTRIC  NERVE 

Immediately  following  the  centers  of  the  glossopharyngeal  nerve 
in  the  medulla  are  the  centers  of  the  great  tenth,  or  the  pneumogastric 
nerve.  The  tenth  nerve  has  an  important  and  extensive  distribution, 
supplying  the  pharynx,  larynx,  lungs,  heart,  esophagus,  and  stomach. 
When  its  nuclei  are  affected  in  the  medulla  the  symptoms  may  be  those 
which  are  grouped  under  the  name  bulbar  paralysis,  and  are  then  usu- 
ally of  toxic  origin.  Affections  may  occur,  however,  of  each  one  of  its 
branches  separately,  and  may  be  considered  in  the  following  order: 
pharyngeal  branches,  in  combination  with  the  glossopharyngeal;  the 
branches  from  the  vagus  form  the  pharyngeal  plexus,  from  which  the 
muscles  and  mucosa  of  the  pharynx  are  supplied.  In  paralysis  due  to 
involvement  of  this,  either  in  the  nuclei,  as  in  bulbar  paralysis,  or  in 
the  course  of  the  nerve,  as  in  diphtheric  neuritis,  there  is  difficulty  in 
swallowing  and  the  food  is  not  passed  on  into  the  esophagus.  If  the 
nerve  on  one  side  only  is  involved,  the  deglutition  is  not  much  im- 
paired. In  these  cases  the  particles  of  food  frequently  pass  into  the 
larynx  and,  when  the  soft  palate  is  involved,  into  the  posterior 
nares. 

Laryngeal  Branches. — The  superior  laryngeal  nerve  supplies  the 
mucous  membrane  of  the  larynx  above  the  vocal  chords  and  the  crico- 
thyroid muscle.  The  inferior  or  recurrent  laryngeal  curves  around  the 
arch  of  the  aorta  on  the  left  side  and  the  subclavian  artery  on  the  right, 
passes  along  the  trachea,  and  supplies  the  mucosa  below  the  cord  and 
at  the  muscles  of  the  larjmx,  except  the  cricothyroid  and  the  epiglot- 
tidean.  Experiments  have  shown  that  these  motor  nerves  of  the  pneu- 
mogastric are  all  derived  from  the  spinal  accessory.  The  remarkable 
course  of  the  recurrent  laryngeal  nerves  renders  them  liable  to  pressure 


PNEUMOGASTRIC   NERVE  599 

by  tumors  within  the  thorax,  particularly  by  aneurysm.  Paralysis  of 
one  or  both  vocal  chords  is  sometimes  the  first  sign  of  the  presence  of  an 
intrathoracic  aneurysm.  The  following  are  the  most  important  forms 
of  paralysis: 

Bilateral  Paralysis  of  the  Abductor's  Chord. — In  this  condition  the 
posterior  crico-arytenoids  are  involved  and  the  glottis  is  not  opened 
during  inspiration.  The  chords  may  be  close  together  in  the  position 
of  phonation,  and  during  inspiration  may  be  brought  even  nearer 
together  by  the  pressure  of  air,  so  that  there  is  only  a  narrow  chink, 
through  which  the  air  whistles  with  a  noisy  stridor.  This  dangerous 
form  of  laryngeal  paralysis  occurs  occasionally  as  a  result  of  cold  or 
may  follow  a  laryngeal  catarrh.  The  posterior  muscles  have  been 
found  degenerated  when  the  others  were  healthy.  The  condition  may 
be  produced  by  pressure  upon  both  vagi  or  upon  both  recurrent  nerves. 
As  a  central  affection  it  occurs  in  tabes  and  bulbar  paralysis,  but  may 
be  seen  also  in  hysteria.  The  characteristic  symptoms  are  inspiratory 
stridor  with  unimpaired  phonation.  Possibly,  as  Gowers  suggests, 
many  cases  of  so-called  hysteric  spasm  of  the  glottis  are,  in  reahty, 
abductor  paralysis. 

Unilateral  Abductor  Paralysis. — This  frequently  results  from  the 
pressure  of  tumors  or  involvement  of  one  recurrent  nerve.  Aneurysm 
is  by  far  the  most  common  cause,  though  on  the  right  side  the  nerve 
may  be  involved  in  thickening  of  the  pleura.  The  symptoms  are 
hoarseness  or  roughness  of  the  voice,  such  as  is  so  common  in  aneurysm. 
Dyspnea  is  not  often  present.  The  chord  on  the  affected  side  does  not 
move  in  inspiration.  Subsequently  the  adductors  may  also  become 
involved,  ti  which  case  the  phonation  is  still  more  impaired. 

Adductor  Paralysis. — This  results  from  involvement  of  the  lateral 
crico-arytenoid  and  the  arytenoid  muscle  itself.  It  is  common  in 
hysteria,  particularly  of  women,  and  causes  the  hysteric  aphonia  which 
may  come  on  suddenly.  It  may  result  from  catarrh  of  the  larynx  or 
from  overuse  of  the  voice.  In  laryngoscopic  examination  it  is  seen,  on 
attempting  phonation,  that  there  is  no  power  to  bring  the  chords  to- 
gether (Osier). 

Spasm  of  the  Muscles  of  the  Larynx. — In  this  the  adductor  muscles 
are  involved.  It  is  not  an  uncommon  affection  in  children,  and  is 
called  laryngismus  stridulus,  or  spasmodic  croup,  and  occurs  in  loco- 
motor ataxia  in  the  so-called  laryngeal  crisis. 

Anesthesia  may  occur  in  bulbar  paralysis  and  in  diphtheric  neuri- 
tis— a  serious  condition,  as  portions  of  food  may  enter  the  windpipe. 

Cardiac  Branches. — The  cardiac  plexus  is  formed  by  the  imion  of 


6oO  CLINICAL  MEDICINE 

branches  of  the  vagi  and  of  the  sympathetic  nerves.     The  vagus  fibers 
subserve  motor,  sensory,  and  probably  trophic  functions. 

Motor. — The  fibers  which  inhibit,  control,  and  regulate  the  cardiac 
action  pass  in  the  vagi.  Irritation  may  produce  slowing  of  the 
action.  Retardation  of  the  heart's  action  has  also  followed  accidental 
ligature  of  one  vagus.  Irritation  of  the  nuclei  may  also  be  accom- 
panied with  a  neurosis  of  this  nerve.  On  the  other  hand,  when  there 
is  complete  paralysis  of  the  vagi  the  inhibitory  action  may  be  abol- 
ished and  the  acceleratory  influences  have  full  sway.  The  heart's 
action  is  then  greatly  increased.  This  is  seen  in  some  instances  of 
diphtheric  neuritis  and  in  involvement  of  the  nerve  by  tumors,  or  its 
accidental  removal  or  ligature.  Complete  loss  of  function  of  one  vagus, 
however,  may  not  be  followed  by  any  S3nnptoms  (Osier), 

SPINAL  ACCESSORY  NERVE 

The  large  external  part  is  distributed  to  the  stemomastoid  and  tra- 
pezius muscles.  Paralytic  affections  of  the  branches  of  the  spinal 
accessory  result  in  difficulty  of  movement  of  the  head.  Thus,  the 
patient  rotates  the  head  to  the  opposite  side,  but  there  is  no  torticolHs, 
though  in  some  cases  the  head  is  held  obHquely.  These  affections, 
however,  are  uncommon  compared  with  spasmodic  contraction  produc- 
ing the  well-known  torticolHs  or  wryneck. 

Congenital  shortening  of  the  stemomastoid  muscle,  accompanied 
in  some  cases  with  facial  as3mimetry,  has  been  mentioned  by  authors, 
but  spasmodic  wrjnieck  is  a  not  uncommon  affection  whose  elements 
are  not  always  easily  diagnosed.  In  my  experience  it  has  been  more 
an  affection  of  women  than  of  men,  and  may  be  very  transient,  but  in 
other  cases  it  begins  with  clonic  spasm,  and  then  passes  on  to  persistent 
tonic  contraction,  naturally  causing  great  distress  to  the  patient.  It 
may  occur  at  all  ages,  but  some  of  the  worst  cases  that  I  have  seen 
have  been  in  elderly  women. 

The  symptoms  are  usually  well  defined.  In  the  tonic  form  the 
contracted  stemomastoid  draws  the  occiput  toward  the  shoulder  of 
the  affected  side;  the  chin  is  raised  and  the  face  rotated  to  the  other 
shoulder.  The  difficulty  of  an  accurate  diagnosis  of  the  affected  mus- 
cles may  occur,  when  not  only  the  stemomastoid  is  affected,  but  in 
association  with  the  trapezius  and  still  more  with  the  deeper  muscles 
that  move  the  neck.  When  the  trapezius  is  affected  the  upper  third 
of  the  muscle  may  not  be  involved  at  all,  but  if  the  whole  muscle  is 
affected  the  head  is  depressed  still  more  toward  the  same  side.  In 
long-standing  cases  these  muscles  are  prominent  and  very  rigid. 


HYPOGLOSSAL   NERVE  6oi 

The  worst  forms  of  this  complaint  are  found  in  those  cases  in  which 
the  neck  muscles  are  affected  with  clonic  spasm,  which  comes  on  every 
minute  or  so,  and  in  which  the  deeper  muscles  may  also  be  involved, 
such  as  the  splenius,  which  may  be  quite  as  often  involved  as  the 
trapezius,  and  also  the  scalenus,  or  by  the  deep  rectus  and  obHquus. 
In  these  diiTerent  affections  the  face,  chin,  and  the  head  itself  may  be 
drawn  into  extraordinary  positions;  in  some  cases  the  face  looks  up- 
ward instead  of  sidewise.  Not  uncommonly  the  contractions  are  pain- 
ful or  may  produce  a  sense  of  distressing  fatigue,  with  the  further  de- 
pressing fact  that  there  is  Httle  prospect  of  cure,  for  if  the  affection 
seems  to  subside  for  a  time,  it  is  pretty  certain  to  recur.  One  mitigat- 
ing circumstance  is  that  the  contractions  cease  during  sleep;  in  the 
waking  state  being  often  excited  or  aggravated  by  emotion. 

It  is  natural  that  in  obstinate  cases  the  patients  resort  to  surgery 
for  rehef,  because  all  attempts  to  overcome  the  spasm  by  fixation  of 
the  head  by  any  apparatus  are  intolerable.  A  surgeon,  however, 
should  not  attempt  to  deal  with  the  affected  muscles,  for,  in  my  ex- 
perience, surgeons  cannot  be  sure  what  muscle  or  tendon  is  to  be  cut, 
and,  instead,  attention  should  be  turned  to  branches  of  the  accessory 
nerve  itself,  which  should  be  resected  as  far  as  possible  along  the 

neck. 

HYPOGLOSSAL   NERVE 

Affections  of  the  hypoglossal  or  motor  nerve  of  the  tongue  as 
separate  or  independent  diseases  are  uncommon.  Thus,  in  hemiplegia 
due  to  any  of  the  ordinary  brain  lesions,  the  tongue  is  not  affected, 
though  the  patient  may  be  wholly  unable  to  use  it  in  cases  of  aphasia. 
It  is  then  quite  intact  in  all  acts  of  mastication  or  deglutition,  its 
nuclei  in  the  medulla,  however,  being  sometimes  involved  in  bulbar 
paralysis  or  possibly  in  tabes. 


CHAPTER  XIX 
DISEASES  OF  THE  CEREBRAL  ARTERIES 

APOPLEXY 

Lesions  of  the  brain,  according  to  their  nature  and  location, 
produce  mental  results  which  raise  the  whole  question  what  a  human 
being  is,  in  contrast  with  other  earthly  beings.  Thus,  speech  is  an 
exclusively  human  faculty.  But  I  had  a  lady  patient  who  woke  one 
morning  to  find  that  she  was  wholly  illiterate,  for  she  could  not  read 
a  word  in  any  language,  though  she  could  hear  and  speak  as  well  as 
ever;  another,  a  gentleman,  who  suddenly  became  unable  to  read  his 
native  English,  but  could  still  read  classic  Greek;  another,  who  could 
hear  the  clock  strike,  but  could  hear  no  word  to  understand  it,  not  even 
his  own  words,  so  that  he  uttered  an  unintelligible  jargon,  while  he 
understood  what  was  said  to  him  and  could  read  as  well  as  ever;  an- 
other, who  could  utter  no  words,  but  still  could  sing  them;  another,  a 
tailor,  who  overnight  permanently  forgot  his  trade  and  had  to  leam 
another  one. 

Now,  in  all  these  instances  what  was  lost  was  not  congenital,  but 
acquired.  But  what  was  it  which  was  acquired?  An  anatomic  seat 
in  the  brain  for  each  of  these  acquirements,  and  when  that  physical 
place  was  damaged  the  corrresponding  acquirement  was  lost. 

But  all  these  facts  fail  to  carry  us  far  enough,  because  we  know  that 
brain  matter  as  such  cannot  acquire  anything  new  or  non-congenital, 
since  one-half  of  brain  matter  remains  without  a  single  acquirement  of 
these  marvelous  mental  endowments  characteristic  of  a  human  person. 
It  is  only  the  left  hemisphere  in  right-handed  persons  and  the  right 
hemisphere  in  the  left  handed  which  can  be  human  in  faculty. 

It  is,  therefore,  not  the  brain,  but  the  person  man  who  can  fashion 
those  physical  seats  of  mental  faculty  in  their  cortical  situations. 

Being  physical,  these  seats  of  mental  faculty  can  be  physically 
injured,  and  this  occurs  almost  wholly  from  something  going  wrong,  not 
in  the  brain,  but  in  the  brain's  blood-vessels.  This  fact  calls  for  the 
most  painstaking  study  of  the  cerebral  circulation,  because  no  calamity 
can  be  greater  than  that  a  little  artery  should  let  blood  escape  into  sur- 
rounding brain  matter  through  such  a  minute  hole  in  the  vessel  wall 

602 


APOPLEXY  603 

that  it  may  be  difficult  to  find  it.  If  the  patient  survives,  his  subse- 
quent history  may  make  one  wish  that  he  had  died  on  the  spot.  The 
causes  of  blood-vessel  diseases,  therefore,  are  among  the  most  vitally 
important  subjects  in  medicine. 

We  begin  with  the  circle  of  Willis,  that  arterial  ring  at  the  base  of 
the  brain  composed  of  a  branch  of  each  internal  carotid  and  each  ver- 
tebral artery.  As  we  proceed,  however,  we  find  that  the  cerebral 
vessels  are  subject  to  lesions  entirely  of  their  own  kind;  namely,  in  the 
form  of  various  small  so-called  mihary  aneurysms,  the  rupture  of  any 
one  of  which  produces  an  effusion  into  the  brain  substance,  which, 
according  to  its  situation,  may  produce  either  apoplexy  or  hemiplegia. 
Many  questions  here  meet  us  about  the  genesis  of  these  remarkable 
aneurysms  because  they  do  not  resemble  any  other  aneurysms. 
Charcot  regards  them  as  due  to  periarteritis,  and  thus  to  weakening  of 
the  adventitia  or  outer  coats.  Other  authors,  like  Birch-Hirschfeld, 
ascribe  them,  and,  in  my  opinion,  with  most  probabihty,  to  lesions  in 
the  intima,  while  others,  like  Roth  and  Lowenthal,  to  lesions  in  the 
media.  These  divergent  views  only  illustrate  the  uncertainty  which 
still  surrounds  this  subject. 

It  is  very  probable  that  the  weak  support  of  surrounding  brain 
matter  renders  the  cerebral  arteries  more  liable  to  locaUzed  lesions  than 
arteries  between  strong  muscular  tissues  or  in  soHd  organs.  Back, 
however,  of  the  chief  causes  of  arterial  disease  there  is  no  difference  of 
opinion,  for  undoubtedly  blood-poisoning  from  imperfect  elimination 
by  the  kidneys  constitutes  the  commonest  cause  of  arterial  weakening 
ever)rwhere  in  the  body.  The  frequency  of  apoplexy  and  of  hemiplegia 
in  persons  .vith  chronic  interstitial  nephritis  lends  support  to  this  view; 
but  another  factor  also  enters  here,  and  that  is,  hypertrophy  of  the 
left  ventricle  of  the  heart  in  arteriosclerosis  due  to  embarrassment  of 
the  arterial  circulation  all  over  the  body.  This  renders  the  cerebral 
arteries  subject  to  unusual  strain,  whether  during  such  acts  as  heavy 
Hfting  or  the  effect  of  emotion  hurrying  the  circulation.  Many  cases, 
therefore,  of  apoplexy  and  hemiplegia  can  be  directly  traceable  to  such 
causes. 

As  we  have  said,  apoplexy  is  not  due  to  any  brain  fault,  but  is 
exclusively  caused  by  something  going  wrong  in  a  cerebral  artery. 
This  may  be  of  more  than  one  kind — one  would  be  by  the  sudden 
plugging  of  a  cerebral  artery  by  an  embolus.  In  such  cases  the  vessel 
may  be  perfectly  healthy,  and  the  embolus  plugs  it  by  reaching  the 
vessel  through  the  blood,  generally  from  as  distant  a  source  as  a  valve 
of  the  heart.     Thus,  a  lady  patient  of  mine  suddenly  lost  all  power  of 


6o4  CLINICAL  MEDICINE 

speech  and  never  regained  it.  I  had  long  known  that  she  had  a  strong 
musical  murmur  at  the  aortic  orifice,  which  disappeared  as  soon  as  she 
had  her  accident.  These  emboli  detached  from  a  diseased  valve  may 
take  a  very  different  course  from  that  to  the  brain.  I  had  a  gentleman- 
whom  I  knew  to  be  affected  with  valvular  disease,  who  first  had  a  severe 
pain  in  the  spleen,  then,  after  an  evening  spent  in  dancing,  he  had 
another  severe  pain  in  his  left  kidney,  accompanied  with  profuse  hema- 
turia, and,  lastly,  while  quietly  reading  a  novel  in  bed,  he  laid  his  book 
down  and  instantly  died.  At  the  postmortem  we  found  that  the  cause 
of  death  was  a  minute  embolus  which  plugged  an  artery  in  the  floor 
of  the  fourth  ventricle,  just  above  the  calamus  scriptorius  or  respira- 
tory center.  An  accident  may  not  be  from  an  embolus,  but  from  a 
thrombus.  These  are  due  to  a  precipitation  on  a  valve,  or,  in  the  course 
of  an  artery,  of  fibrin,  and  this  may  be  dislodged,  so  that  it  will  closely 
resemble  the  effect  of  an  embolus.  But  in  many  cases  thrombi  may 
form  gradually,  and,  therefore,  may  cause  their  symptoms  not  suddenly, 
but  relatively  more  slowly.  A  patient  with  cerebral  thrombosis  may, 
therefore,  be  at  first  conscious,  but,  as  the  thrombus  increases  in  size, 
he  may  have  his  symptoms  change  accordingly.  It  is  often  a  question 
whether  a  cerebral  lesion  is  hemorrhagic,  emboHc,  or  thrombic.  In 
favor  of  its  being  due  to  thrombosis  is  the  previous  presence  of  disease 
in  the  arteries,  whether  of  the  nature  of  atheroma  or  of  a  regular  calci- 
fication in  the  walls  of  the  blood-vessels.  Thus,  an  embolus  may  occur 
in  a  perfectly  healthy  artery,  but  a  thrombus  is  usually  caused  by 
long-standing  arterial  disease.  When  the  case  is  one  of  true  apoplexy 
we  should  take  several  considerations  into  account.  One  is  that  apo- 
plectic attacks  are  apt  to  occur  after  hearty  meals,  the  explanation  of 
which  is  that  there  is  a  striking  provision  in  the  functions  of  the  kidneys 
to  eliminate  a  much  greater  quantity  of  urea  after  a  meal  than  before 
it.  This  provision  is  to  maintain  the  balance  of  the  circulation,  so 
that  when  much  is  added  to  it  the  kidney  should  correspondingly  be 
more  active  in  its  elimination.  Should,  however,  the  kidneys  be  dis- 
eased, vascular  disorders  are  quite  sure  to  accompany  it,  and  hence  they 
may  be  unable  to  respond  promptly  to  the  demand  made  upon  them. 
The  attacks  of  apoplexy  may  be  very  sudden  and  quickly  followed  by 
death.  In  other  cases  the  patients  may  suddenly  feel  faint  and  fall, 
shortly  afterward  becoming  unconscious,  particularly  if,  which  is  very 
common,  they  have  attacks  of  vomiting.  From  the  congestion  of  the 
head  produced  by  the  act  of  vomiting  it  is  to  be  avoided  as  much  as 
possible,  usually  by  a  patient  being  immediately  made  recumbent. 
Should  the  physician  being  called  to  a  case  for  the  first  time  find  a 


APOPLEXY  605 

patient  comatose,  he  has  immediately  to  decide  what  the  cause  of  the 
coma  is.  It  may  be  from  a  blow  on  the  head.  Thus,  I  had  a  hospital 
patient  who  was  admitted  with  no  history.  He  was  laughing  and  act- 
ing in  a  very  silly  manner,  and,  moreover,  he  had  an  alcoholic  breath. 
I  hastily  concluded  that  he  was  drunk,  but  before  I  left  the  hospital  I 
was  called  to  see  him  again  and  found  him  dead.  Postmortem  showed 
that  he  had  a  large  subdural  blood-clot,  caused  by  his  having  been 
struck  by  a  sand-bag  while  in  a  drunken  row. 

But  the  patient  may  be  suffering  from  uremic  coma,  in  which  case 
the  pupils  may  be  irregular  and  also  the  breathing.  The  pulse  in 
apoplexy  and  also  in  uremia  is  generally  full  and  of  high  tension.  In 
apoplexy,  however,  the  movements  of  the  hands  should  be  very  care- 
fully noted.  The  one  hand  will  be  found  not  to  move,  while,  if  the  arm 
be  raised  and  then  dropped,  there  will  be  a  marked  difference  between 
the  two  sides,  the  paralyzed  arm  dropping  at  once,  while  the  other  arm 
is  much  slower  in  falling;  or  the  patient  may  be  suffering  from  diabetic 
coma,  in  which  case  the  breathing  is  usually  very  shallow,  and  there 
will  be  a  sweetish  odor  to  the  breath ;  or  the  patient  may  be  comatose 
from  a  poisonous  dose  of  opium;  in  this  latter  case  there  will  be  sym- 
metric contraction  of  the  pupils  and  slow  breathing. 

Apoplexy  from  effusion  of  blood,  if  the  patient  survives,  will  soon 
show  the  signs  of  hemiplegia  present  in  the  face  and  in  the  arm  and 
lower  extremity  on  one  side.  In  the  face  there  will  be  an  alteration  in 
the  lines  of  the  cheek  and  the  mouth  on  one  side  compared  with  the 
other,  with  the  signs  of  paralysis  of  the  upper  and  lower  extremity  we 
have  already  alluded  to.  The  subsequent  history  when  the  patient 
has  recovered  consciousness  differs  according  to  the  case.  If  the  paral- 
ysis is  on  the  right  side,  and  the  patient  is  as  usual  right-handed,  he 
will  also  have  aphasia,  but,  though  he  cannot  use  his  tongue  for  speak- 
ing or  protruding  it  when  asked,  he  can  use  the  tongue  as  well  as  ever 
in  the  act  of  swallowing.  In  these  cases  the  arm  is  usually  more  para- 
lyzed than  the  leg. 

Changes  in  the  brain  tissue  are  not  uncommon  effects  of  apoplexy 
or  of  closure  of  the  blood-supply  to  a  part  due  to  an  embolus  or  to  a 
thrombus.  After  a  branch  of  a  cerebral  artery  has  been  plugged  by 
an  embolus  or  closed  by  a  thrombus,  changes  often  occur  in  the  terri- 
tory supplied  by  the  affected  artery  which  are  of  the  nature  of  soften- 
ing. If  the  artery  implicated  belongs  to  the  cortex  these  anatomic 
changes  are  not  very  pronounced,  because  of  the  numerous  anastomoses 
of  the  cortical  blood-vessels.  But  if  they  occur  in  the  region  of  basal 
ganglia  the  effects  are  more  serious,  because  the  arteries  here  are  ter- 


6o6  CLINICAL  MEDICINE 

minal  and  do  not  anastomose.  The  part  supplied  by  the  affected  artery- 
then  becomes  first  necrosed,  and  soon  breaks  up  into  a  softened  tissue 
which  may  be  absorbed,  leaving  a  scar  or,  instead,  form  a  cyst. 

Treatment. — The  symptoms  accompanying  an  attack  of  apoplexy 
may  be  of  two  opposite  kinds.  In  the  first  the  face  is  flushed,  the  pulse 
full,  and  of  high  tension.  If  this  persists  for  more  than  an  hour  the 
indication  is  to  bleed  the  patient  until  the  pulse  becomes  soft.  In 
other  cases  the  face  is  pale  and  the  pulse  weak,  conditions  due  to  gen- 
eral shock.  In  such  cases  stimulants  may  be  cautiously  administered, 
the  best  of  which  is  brandy,  to  be  discontinued  so  soon  as  the  signs 
of  reaction  set  m.  Absolute  bodily  quiet  is  unperative  in  all  forms. 
Meantime  the  bowels  should  be  opened  freely.  If  the  patient  in  coma 
is  unable  to  swallow,  i  or  2  drops  of  croton  oil  should  be  placed  on  the 
tongue,  for  this  soon  acts  on  the  bowels. 

HEMIPLEGIA 

The  different  features  of  hemiplegia  follow,  and  may  be  the  most 
permanent  results  of  an  attack  of  apoplexy.  We  have  already  spoken 
of  the  early  recognition  of  hemiplegia  as  it  shows  itself  in  paralysis  of 
muscles  in  the  face,  arm,  and  leg  on  one  side.  Usually  the  muscles 
of  the  neck  and  of  the  ribs  escape,  which  is  explained  by  Broadbent  as 
due  to  their  innovation  being  bilateral  in  the  brain  and  medulla  instead 
of  unilateral.  One  of  the  early  signs  may  be  a  rigidity  of  the  muscles 
on  the  affected  side,  which  must  be  distinguished  from  late  rigidity, 
for  early  rigidity  may  not  last  longer  than  one  day,  while  late  rigidity 
comes  on  slowly,  and  may  last  for  the  rest  of  the  patient's  Hfetime. 
The  patient  should  be  watched  at  the  beginning,  that  he  does  not  throw 
his  hand,  foot,  or  leg  out  of  the  bed  from  reflex  movements  proceeding 
from  the  spinal  cord.  Here  we  may  say  that  the  physician  in  every 
case  of  apoplexy,  with  or  without  hemiplegia,  should  be  careful  to  per- 
cuss over  the  pubes  to  determine  whether  there  is  retention  of  urine  in 
the  bladder.  I  have  known  of  serious  results  coming  from  forgetting 
this  precaution,  because  retention  of  urine  after  such  cerebral  accidents 
is  apt  to  occur.  The  condition  of  the  back  should  be  noted  at  every 
visit  for  the  first  signs  of  the  formation  of  a  bed-sore,  which  is  par- 
ticularly prone  to  occur  after  dribbling  of  urine  from  an  overdistended 
bladder.  Quiet  from  bodily  movements  is  necessarily  incumbent 
after  apoplexy  or  hemiplegia  has  occurred,  and  it  is  only  when  the 
chronic  effects  of  paralysis  have  developed  that  anything  but  quiet  is 
indicated.  The  patient  or  his  friends  may  importune  the  physician 
to  use  every  means  for  restoring  muscular  power,  and  particularly  ask 


HEMIPLEGIA  607 

for  the  employment  of  electricity,  but  the  latter  is  absolutely  useless 
at  this  stage  for  any  purpose.  As  soon  as  all  irritative  symptoms  have 
subsided,  the  patient  may  be  allowed  to  sit  up  and  attempt  to  walk. 
His  gait,  then,  is  quite  characteristic,  because  the  leg  hangs  helpless 
from  the  pelvis  down;  but,  as  the  trunk  muscles  still  act,  he  swings 
the  leg  from  the  pelvis  in  a  curved  line,  the  toes,  however,  scraping  the 
floor.  This  movement  at  once  differentiates  the  walk  from  that  of 
hysteric  hemiplegia,  for  in  that  affection  the  foot  is  dropped  flat  in 
the  movement  of  the  body. 

After  a  time,  late  rigidity  sets  in,  beginning  usually  with  the  para- 
lyzed hand,  and  in  which  the  thumb  is  strongly  flexed  into  the  palm. 
The  forearm  also  is  flexed  and  drawn  inward  toward  the  middle  line, 
in  some  cases  making  it  impossible  to  straighten  the  arm. 

Meantime  there  is  always  an  increased  knee-jerk  on  the  sound  side. 
In  time  the  nutrition  of  both  the  skin  and  of  the  muscles  suffers  on  the 
paralyzed  side,  the  limb  feels  cold,  and  its  muscles  atrophy,  particu- 
larly if  the  late  rigidity  is  pronounced.  In  most  cases  sensation  is  not 
nearly  so  much  affected  as  motion. 

The  treatment  of  the  late  results  of  hemiplegia  is  first  to  counteract 
the  results  of  late  rigidity.  We  have  only  one  agent  which  at  all  re- 
lieves this  muscular  condition,  and  that  is  the  douche  of  hot  water, 
appHed  night  and  morning.  Now  we  may  find  electricity  of  service 
by  using  the  faradic  current  on  the  paralyzed  muscles,  group  by  group, 
for  this  current  always  increases  the  flow  of  blood  through  the  muscles, 
and  thus  helps  to  keep  up  its  nutrition. 

This  is  the  proper  place  to  mention  that  valuable  sign  in  organic 
nervous  lesions  called  Babinsky's  reflex.  This  reflex  is  ehcited  by  tick- 
ling the  inner  surface  of  the  sole  of  the  foot,  when  the  behavior  of 
the  toes  ought  to  be  specially  noted.  In  health  the  great  toe  is 
strongly  extended,  while  the  other  toes  are  flexed,  but  when  this  result 
does  not  occur,  it  is  a  sure  sign  of  organic  change  in  the  spinal  cord. 
This  reflex  does  not  occur  in  hysteria. 

"The  facial  or  seventh  may  be  paralyzed  by  (a)  lesions  of  the  cortex 
— supranuclear  palsy;  {b)  lesions  of  the  nucleus  itself;  or  (c)  involve- 
ment of  the  nerve-trunk  in  its  tortuous  course  within  the  pons  and 
through  the  wall  of  the  skull. 

"(a)  Supranuclear  paralysis,  due  to  lesion  of  the  cortex  or  of  the 
facial  fibers  in  the  corona  radiata  or  internal  capsule,  is,  as  a  rule,  asso- 
ciated with  hemiplegia.  It  may  be  caused  by  tumors,  abscess,  chronic 
inflammation,  or  softening  in  the  cortex  or  in  the  region  of  the  internal 
capsule.     It  is  distinguished  from  the  peripheral  form  by  wefl-marked 


6o8  CLINICAL  MEDICINE 

characters — the  persistence  of  the  normal  electric  excitability  of  both 
nerves  and  muscles,  and  the  frequent  absence  of  involvement  of  the 
upper  branches  of  the  nerve,  so  that  the  orbicularis  palpebrarum,  fron- 
tahs,  and  corrugator  muscles  are  spared.  In  rare  instances  these 
muscles  are  paralyzed.  In  this  form  the  volimtary  movements  are 
more  impaired  than  the  emotional.  Isolated  paralysis — monoplegia 
faciahs — due  to  involvement  of  the  cortex  or  of  the  fibers  in  their  path 
to  the  nucleus  is  uncommoii.  In  the  majority  of  cases  supranu- 
clear facial  paralysis  is  part  of  a  hemiplegia.  Paralysis  is  on  the  same 
side  as  that  of  the  arm  and  leg,  because  the  facial  muscles  bear  precisely 
the  same  relation  to  the  cortex  as  the  spinal  muscles.  The  nuclei  of 
origin  on  either  side  of  the  middle  line  in  the  medulla  are  united  by 
decussating  fibers  with  the  cortical  center  on  the  opposite  side.  A 
few  fibers  reach  the  nucleus  from  the  cerebral  cortex  of  the  same  side, 
and  this  uncrossed  path  may  innervate  the  upper  facial  muscles. 

"(&)  The  nuclear  paralysis  caused  by  lesions  of  the  nerve-centers 
in  the  medulla  is  not  common  alone,  but  is  seen  occasionally  in  tumors, 
chronic  softening,  and  hemorrhage.  It  may  be  involved  in  anterior 
poliomyelitis.  In  diphtheria  this  center  may  also  be  attacked.  The 
symptoms  are  practically  similar  to  those  of  an  affection  of  the  nerve- 
fiber  itself — infranuclear  paralysis. 

"(c)  Involvement  of  the  Nerve-trunk. — Paralysis  may  result  from 
involvement  of  the  nerve  as  it  passes  through  the  pons,  that 
is,  between  its  nucleus  in  the  floor  of  the  fourth  ventricle  and  the 
point  of  emergence  in  the  posterolateral  aspect  of  the  pons.  The 
specially  interesting  feature  in  connection  with  involvement  of  this 
part  is  the  production  of  what  is  called  alternating  or  crossed  paralysis, 
the  face  being  involved  on  the  same  side  as  the  lesion,  and  the  arm  and 
leg  on  the  opposite  side,  since  the  motor  path  is  involved  above  the 
point  of  decussation  in  the  medulla.  This  occurs  only  when  the  lesion 
is  in  the  lower  section  of  the  pons.  A  lesion  in  the  upper  half  of  the 
pons  does  not  involve  the  fibers  of  the  outgoing  nerve  on  the  same  side, 
but  the  fibers  from  the  hemispheres  before  they  have  crossed  to  the 
nucleus  of  the  opposite  side.  In  this  case  there  would  of  course  be,  as 
in  hemiplegia,  paralysis  of  the  face  and  limbs  on  the  side  opposite  to 
the  lesion.  The  palsy,  too,  would  resemble  the  cerebral  form,  involv- 
ing only  the  lower  fibers  of  the  facial  nerve"  (Osier). 

Treatment. — Besides  the  measures  which  we  have  enumerated  for 
the  treatment  of  the  late  rigidity  of  the  muscles,  local  attention  to  the 
paralyzed  muscles  should  be  tried.  Such  muscles  are  very  prone  to 
atrophy,  and  their  circulation  becomes  deficient,  the  paralyzed  parts 


HEMIPLEGIA  609 

feeling  cold.  It  is  then  that  the  faradic  current  should  be  used  to 
restore  the  circulation  and  nutrition  of  the  palsied  parts,  and  so  far 
as  possible  each  muscle  or  group  of  muscles  should  be  traversed  by 
this  current.  If  any  rigidity  still  remains,  the  hot-water  douche  should 
be  used  to  relax  it,  and  then  the  electricity  immediately  applied.  By 
perseverance  in  these  measures  it  is  often  gratifying  to  note  how  the 
nutrition  of  the  muscles  may  be  preserved,  and  we  should  always  have 
recourse  certainly  at  first  to  them,  for  we  can  never  be  sure  whether 
the  paralysis  is  going  to  remain  complete  or  be  partial.  On  the 
same  principle,  whatever  keeps  up  the  local  circulation  should  be 
thought  of,  and  hence  massage  and  passive  exercise  of  the  parts  should 
be  resorted  to  twice  a  day,  care  being  taken  not  to  commence  massage 
until  we  are  sure  that  the  immediate  effects  of  the  lesion  have  passed  off. 

In  conditions  both  of  apoplexy  and  hemiplegia  the  eyes  may  be 
examined  to  note  what  is> called  conjugate  deviation,  meaning  that  both 
eyes  are  turned  to  one  side.     Osier  says: 

* 'Conjugate  Deviation. — In  a  right  hemiplegia  the  eyes  and  head 
may  be  turned  to  the  left  side;  that  is  to  say,  the  eyes  look  toward  the 
cerebral  lesion.  This  is  ahnost  the  rule  in  the  conjugate  deviation  of 
the  head  and  eyes  which  occurs  early  in  hemiplegia.  When,  however, 
convulsions  or  spasm  occur,  or  the  state  of  so-called  early  rigidity  in 
hemiplegia,  the  conjugate  deviation  of  the  head  and  eyes  may  be  in  the 
opposite  direction;  that  is  to  say,  the  eyes  look  away  from  the  lesion 
and  the  head  is  rotated  toward  the  convulsed  side.  This  symptom 
may  be  associated  with  cortical  lesions,  particularly,  according  to  some 
authors,  when  in  the  neighborhood  of  the  supramarginal  and  angular 
gyri.  It  may  also  occur  in  a  lesion  of  the  internal  capsule  or  in  the 
pons,  but  in  the  latter  situation  the  conjugate  deviation  is  the  reverse 
of  that  which  occurs  in  other  cases,  as  the  patient  looks  away  from  the 
lesion,  and  in  spasm  or  convulsion  looks  toward  the  lesion." 

With  reference  to  hemorrhage  in  the  cms,  Osier  states: 

'■^Crus. — The  bleeding  may  extend  from  vessels  supplying  the  cor- 
pus striatum,  internal  capsule,  and  optic  thalamus,  or  the  hemorrhage 
may  be  primarily  in  the  cms.  In  the  classical  case  of  Weber,  on  sec- 
tion of  the  lower  part  of  the  left  crus,  an  oblong  clot,  15  mm.  in.  length, 
lay  just  below  the  medial  and  inferior  surface.  The  characteristic 
features  of  a  lesion  in  this  locality  are  paralysis  of  arm,  face,  and  leg  of 
the  opposite  side,  and  oculomotor  paralysis  of  the  same  side — the  syn- 
drome of  Weber.  Sensory  changes  may  also  be  present.  Hemorrhage 
into  the  tegmentum  is  not  necessarily  associated  with  hemiplegia,  but 
there  may  be  incomplete  paralysis  of  the  oculomotor  nerve,  with  dis- 
39 


6lO  CLINICAL  MEDICINE 

turbance  of  sensation  and  ataxia  on  the  opposite  side  of  the  body.  The 
optic  tract  or  the  lateral  geniculate  body  lying  on  the  lateral  side  of  the 
crus  may  be  compressed,  in  which  event  there  will  be  hemianopia." 

INSOLATION,   OR  SUNSTROKE 

There  is  no  physiologic  fact  more  interesting  than  the  extraordinary 
uniformity  in  the  degree  of  the  blood-heat  in  man,  however  different 
the  heat  may  be  outside  of  his  body.  Thus,  the  temperature  of  the 
blood  is  the  same  whether  he  be  on  the  shores  of  the  Arctic  Ocean  or 
at  the  equator — namely,  98.5°  F.  The  blood  of  the  internal  organs, 
especially  when  they  are  active  in  function,  may  rise  one  degree  above 
this  point.  On  the  shores  of  the  Red  Sea  the  average  temperature  of 
the  air  is  22°  F.  above  that  of  the  blood,  but  this  has  no  effect  whatever 
in  altering  the  normal  figure. 

In  the  latter  part  of  the  eighteenth  century  Dr.  Bladgen,  president 
of  the  Royal  Society,  with  Dr.  Fordyce,  having  noted  how  certain 
showmen  went  into  ovens  and  there  baked  bread,  concluded  them- 
selves to  perform  the  same  experiment.  They  stayed  in  the  oven  mitil 
they  cooked  a  beefsteak  in  thirteen  minutes;  while  they  were  doing  so 
their  breath  on  their  hands  felt  decidely  cold,  and  they  could  not 
touch  their  watch  chains  because  they  were  so  hot.  Meanwhile  the 
thermometer  under  their  tongues  did  not  vary  from  the  normal. 
This  proves  that  if  the  temperature  is  either  above  or  below  normal 
that  such  changes  must  be  due  to  internal  and  not  external  causes. 
But  it  was  not  until  our  day  that  the  thermometer  was  used  for  such 
important  purposes  as  it  is  now  for  judging  the  conditions  of  the 
body  in  disease. 

One  of  the  most  noted  places  for  the  occurrence  of  sunstroke  is 
New  York  City.  During  the  hot  days  which  close  the  month  of  June 
and  the  beginning  of  July,  when  deaths  from  insolation  may  reach 
75  a  day,  I  have  gone  into  my  wards  at  the  Roosevelt  Hospital  to 
find  a  scene  that  would  resemble  a  battlefield,  from  the  number  of 
persons  who  were  lying  on  the  floor  unconscious,  the  attendants  wait- 
ing for  the  opportunity  to  put  them  in  ice-water  baths.  Much  the 
greater  number  of  such  cases  were  draymen,  exposed  to  the  sun  as  they 
drove  about  the  city,  but  it  was  very  noticeable  how,  upon  investigation, 
the  majority  of  these  men  were  consumers  of  alcohol. 

I  was  struck  in  reading  the  life  of  the  celebrated  British  general. 
Sir  Charles  Napier,  how  he  ascribed  his  immunity  from  sunstroke,  com- 
pared with  that  of  his  fellow  officers,  to  his  total  abstinence  from  liquors 
during  an  active  campaign  on  the  hot  plains  in  the  Punjab. 


INSOLATION,    OR    SUNSTROKE  6 II 

As  we  have  remarked  before,  the  most  important  center  of  the  vaso- 
motor system  of  nerves  is  at  the  nape  of  the  neck,  for  it  controls  the 
circulation  of  the  head  and  face,  and,  moreover,  has  close  relation  to  the 
action  of  the  heart  and  the  circulation  of  the  lungs.  It  is  on  the  vaso- 
motor system  that  the  chief  derangements  of  the  circulation  occur 
from  the  effects  of  sunstroke.  Thus,  in  persons  who  recover,  the  major- 
ity will  suffer  for  years  or  Ufe  from  flushing  of  the  head  and  face  on 
sHght  causes,  and  from  palpitation  or  giddiness.  Conscious  of  their 
loss  of  self-control  they  have  no  confidence  in  themselves,  and  remain 
permanently  unable  to  expose  themselves  to  the  hot  sun  for  the  same 
reason.     They  are  also  very  hable  to  have  frequent  headaches. 

The  immediate  symptoms  of  sunstroke  vary  in  different  cases. 
One  form  is  that  of  general  prostration,  not  unhke  persons  who  have 
had  an  attack  of  syncope  from  which  they  have  not  recovered.  In 
them  the  pulse  is  weak,  the  countenance  pale,  the  breathing  short  and 
rapid,  and  the  skin  actually  cool  to  the  touch;  the  temperature,  how- 
ever, measured  by  a  thermometer  in  the  rectum,  may  be  high. 

But  so  long  as  the  skin  feels  cool  to  the  touch  and  the  pulse  is  weak, 
heart  stimulants  should  be  freely  used,  of  which  far  the  best  is  the  hy- 
podermic injection  of  7^j  gr.  of  camphor  in  steriHzed  almond  or  olive 
oil. 

The  most  common  effect  of  sunstroke,  however,  is  to  produce  hy- 
perpyrexia, the  temperature  rising  from  io6°  to  iio°  F.,  sometimes 
reaching  the  higher  figure  after  death.  This  hyperpyrexia  is  one 
cause  of  the  patients  being  frequently  comatose  when  they  are  brought 
in.  As  we  have  remarked  when  speaking  of  the  hyperpyrexia  which 
sometimes  occurs  in  rheumatic  fever,  the  only  effective  remedy  is  the 
ice-bath.  On  emersing  the  body  in  the  water,  the  head  should  have  an 
ice-cap  applied  to  it,  and  then,  as  in  the  case  of  rheumatic  fever,  the 
temperature  should  be  carefully  watched  and  the  patient  removed 
before  the  thermometer  has  dropped  to  ioo°  F.,  the  surface  circulation 
being  kept  up  by  active  rubbing.  As  we  have  remarked  before,  the 
first  effect  of  emersing  in  the  bath  is  to  raise  the  temperature  from 
one  to  two  degrees,  but  it  soon  falls  by  the  time  the  patient  recovers 
consciousness.  Usually  in  insolation  the  temperature  does  not  rise 
again  after  the  bath,  while  in  the  hyperpyrexia  of  rheumatic  fever  it 
may  progressively  rise  in  the  course  of  an  hour  toward  its  former  figure, 
and  calls  for,  it  may  be,  ten  successive  baths. 

In  many  cases  patients  are  taken  with  thermic  fever  while  they 
are  not  exposed  to  the  sun,  but  only  suffering  from  the  excessive  heat 
of  the  air;  they  are  then  said  to  be  sufferers  from  heatstroke.     Sir 


6l2  CLINICAL  MEDICINE 

Joseph  Fayrer  reports  numerous  cases,  in  his  large  experience  in  India, 
where  the  patients  were  overcome  while  they  were  in  bed,  either  on  ship- 
board or  on  land ;  these  patients  present  all  the  characters  of  the  effects 
of  sunstroke  itself,  either  of  great  prostration,  with  symptoms  of  heart 
failure  or  an  active  deHrium,  or  occasionally  with  signs  of  apoplexy  or 
even  of  hemiplegia.  The  treatment,  however,  is  the  same  as  that 
given  for  sunstroke. 

The  knowledge  of  the  after-effects  of  sunstroke  should  be  borne  in 
mind  by  every  physician;  the  derangements  due  to  injury  or  paralysis 
of  the  vasomotor  centers  may  continue  for  years.  We  have  very  few 
remedies  for  this,  except  one,  which  should  be  daily  resorted  to  for 
months.  On  rising  in  the  morning  a  douche  of  two  or  three  pitchers 
of  cold  water  should  be  poured  upon  the  nape  of  the  neck,  followed  by 
friction.  Care,  however,  should  be  taken  meanwhile  to  protect  the 
hair  from  being  wet  by  use  of  linen  towels.  Occasionally,  though  not 
commonly,  it  is  the  splanchnic  nerves  which  are  affected,  with  disturb- 
ances in  the  circulation  of  the  abdominal  viscera,  especially  after  heat- 
stroke, in  which  case  the  douche  should  be  apphed  to  the  lower  part 
of  the  spine.  I  have  thought  that  the  nitrate  of  silver  in  |-gr.  doses 
is  a  good  remedy  in  vasomotor  complaints,  but  after  using  these  doses 
for  six  weeks  this  drug  should  be  omitted.  The  same  doses  of  the 
sulphate  of  zinc  or  the  sulphate  of  copper  may  be  substituted. 

Examination  of  the  body  after  death  from  sunstroke  frequently  re- 
veals an  extraordinary  prevalence  of  what  are  called  the  terminal  infec- 
tions by  bacteria,  which  are  found  in  great  numbers  in  the  brain  as 
well  as  elsewhere.  It  is  doubtful,  however,  whether  these  are  not  the 
results  of  postmortem  changes. 


CHAPTER  XX 
DISEASES  OF  THE  BRAIN 

INTRODUCTION 

In  former  times  edema  of  the  brain  was  considered  to  be  a  fre- 
quent complaint,  so  that  authors  spoke  of  serous  apoplexy.  We  now 
know,  however,  that  it  is  very  uncommon,  and  when  a  brain  is  found 
to  contain  an  abnormal  quantity  of  serous  or  watery  fluid  in  its  sub- 
stance it  is  mostly  due  to  a  general  dropsical  condition  in  the  body,  com- 
monly found  in  parenchymatous  nephritis;  it  is,  therefore,  not  a  morbid 
condition  by  itself. 

Delirium. — It  is  very  natural  that  the  laity  should  ascribe  dehrium 
to  an  affection  of  the  brain.  The  fact  is,  however,  that  the  brain  is 
but  rarely  affected  in  cases  of  dehrium.  Thus,  among  the  acute  in- 
flammations, croupus  pneumonia  is  marked  in  its  course  with  con- 
tinuous dehrium  until  the  crisis  occurs,  but  when  the  case  ends  in 
death  the  postmortem  derangements  are  hmited  to  the  limgs  and  not 
at  all  to  the  brain.  So  in  all  kinds  of  dehrium,  as  in  t>^hoid  fever,  the 
case  is  just  the  same,  so  far  as  the  brain  is  concerned. 

But  we  may  go  even  further,  and  see  that  in  cases  of  true  insanity 
the  brain  after  death  is  found  absolutely  normal,  except  in  paresis  or 
general  paralysis  of  the  insane,  in  which  the  brain  is  organically  affected 
much  as  thj  spinal  cord  is  affected  in  tabes,  and  for  the  same  reason, 
that  it  is  a  chronic  result  of  the  virus  of  syphiUs.  Hence,  dehrium  is  not 
due  to  derangement  of  the  brain,  but  to  various  derangements  of  the 
blood,  and  most  cases  of  insanity  are  best  treated  as  blood  disorders. 

APHASIA 

The  faculty  of  speech  is  exclusively  human.  It  is  the  highest  and, 
at  the  same  time,  most  artificial  of  endowments,  because  it  depends 
upon  the  integrity  of  its  anatomic  seats,  which  are  themselves  created 
by  the  person  himself,  for  no  one  else  can  do  it  for  him.  Thus,  when 
one  learns  a  new  language,  he  cannot  do  so  by  proxy.  But  when  he  has 
learned  it,  its  words  are  deposited  in  his  brain  on  a  distinct  layer  of 
brain  tissue  resembling  the  different  wax  leaves  of  a  phonograph. 
Now  these  speech  layers  may  be  separately  damaged,  while  the  others 

613 


6 14  CLINICAL   MEDICINE 

remain  intact.  Thus,  many  cases  have  been  reported  of  persons  who 
have  learned  French  or  German  after  their  native  English,  and  have 
suffered  some  injury,  like  an  apoplectic  clot,  which  destroyed  their 
English  layer,  so  that  subsequently  they  could  speak  only  in  the  later 
acquired  language. 

The  point  of  interest  here  is  that  the  speech-centers  in  the  brain 
are  never  congenital,  but  are  made  by  the  speaker.  The  first  attempts 
of  a  child  are  by  gesture,  and  gesture  language  remains  an  important 
department  of  speech  to  the  end  of  Ufe;  therefore  the  most  used  hand 
in  childhood  settles  which  of  the  two  cerebral  hemispheres  shall  con- 
tain the  anatomic  seats  of  speech,  and  hence  these  will  be  found  in  the 
left  hemisphere  of  right-handed  persons  or  in  the  right  hemisphere  of 
the  left  handed. 

Further  investigation  shows  that,  according  to  its  anatomic  seats, 
speech  is  either  sensory  (consisting  of  words  that  come  to  us  either 
through  the  ear  in  listening  or,  again,  through  the  eye  in  reading)  or 
motor,  which  are  words  which  we  ourselves  utter  by  the  comphcated 
apparatus  of  the  muscles  of  the  larynx,  tongue,  and  lips,  or  by  the 
hand  in  writing. 

The  different  anatomic  seats  of  words  are  in  the  first  temporal 
convolutions  for  words  which  reach  us  through  the  ear,  and  the  angu- 
lar gyrus  for  words  which  come  through  the  eye.  The  anatomic  seats 
of  motor  speech  are  at  the  base  of  the  third  frontal  convolution,  called 
Broca's  convolution,  or  its  neighborhood.  The  seat  of  writing  is  not 
so  well  determined,  but  recent  researches  render  it  probable  that  it  is  in 
the  posterior  part  of  the  second  frontal  convolution.  There  can  be  no 
doubt  that  the  center  for  arithmetic  figures  must  be  quite  separate  from 
either  of  these.  I  had  a  patient  who  was  perfectly  word-blind,  so  that 
he  could  not  read,  and  who  also  could  not  utter  a  single  word,  but 
who  could  both  read  and  write  and  calculate  the  most  complicated 
arithmetic  figures  in  his  business.  These  facts  can  all  be  demonstrated 
by  postmortem  findings.  Limited  lesions  in  the  temporal  convolutions 
have  been  found  which  caused  total  word-deafness  without  any  other 
kind  of  deafness.  These  patients  cannot  hear  their  own  words,  so 
that  when  they  speak  they  use  an  unintelligible  jargon.  Limited 
lesions  in  the  angular  gyrus  also  produce  total  word-bhndness,  so  that 
the  patients  see  everything  well  except  words.  Likewise,  derangements 
of  motor  speech  are  very  common,  in  which,  owing  to  njury  of  its  cen- 
ters, the  patient,  though  he  can  hear  and  see  words,  is  yet  totally  unable 
to  utter  them. 


APHASIA  615 

More  than  anything  else,  the  study  of  ajjhasia  has  led  to  the  dis- 
covery and  defmition  of  those  most  important  subcortical  fibers  in  the 
brain  which  are  called  association  libers.  These  are  very  numerous, 
so  that  they  constitute  the  chief  part  of  the  white  substance  of  the  brain. 
Their  office  is  to  bring  into  relation  the  different  psychical  or  mental 
operations.  Thus,  we  have  spoken  of  the  centers  for  word  hearing, 
word  seeing,  and  word  uttering,  but  if  we  were  furnished  with  only 
those  centers  our  speech  would  be  scarcely  better  than  that  of  parrots. 
It  is  by  means  of  these  numerous  association  fibers  that  the  different 
cortical  centers  are  made  to  work  together. 

We  may  here  pause  for  a  moment  to  explain  the  mechanism  of 
dreams.  In  dreams  we  have  the  same  subjective  acts  of  seeing,  hear- 
ing, and  feeling  which  we  have  when  awake,  and  on  that  account,  how- 
ever absurd,  they  never  excite  wonder,  for  the  centers  are  working  in- 
dependently without  the  correction  of  association  fibers. 

"These  association  fibers  may  be  quite  short  when  they  pass  be- 
tween adjacent  convolutions,  but  both  long  and  broad  in  the  tract 
which  passes  from  the  frontal  lobe,  collecting  its  bundle  from  all  three 
convolutions  backward  to  the  occipital  lobe. 

"A  second  tract  joins  the  occipital  with  the  anterior  part  of 
the  temporal  lobe,  a  third  tract  passes  from  the  upper  two  temporal 
convolutions  forward  to  the  third  frontal  convolution,  and  a 
fourth  tract  passes  from  the  frontal  to  the  posterior  temporal  area" 
(Starr). 

Without  these  association  fibers  intelhgible  speech  would  be  im- 
possible, but  the  different  speech  disorders  can  frequently  be  distin- 
guished by  the  signs  which  indicate  lesions  in  the  cortical  centers  them- 
selves, or  m  the  subcortical  distribution  of  the  association  fibers. 
These  latter  produce  mental  derangements,  so  that  we  can  speak  of 
word-blindness  as  such,  or  psychical  word-blindness,  and  these  same 
terms  may  be  used  for  the  other  derangements. 

From  the  nature  of  the  disorder,  instances  of  aphasia  which  can  be 
certainly  accepted  as  affording  clinical  evidence  of  definite  localization  of 
speech  centers  are  necessarily  few.  The  lesions  must  be  too  exclusively 
limited  to  the  speech  centers  or  their  connections  to  be  at  all  common 
even  from  trauma,  and  still  less  from  disease.  When  important  centers 
other  than  the  speech  centers  are  also  involved,  as  in  every  case  of  hemi- 
plegia, the  inferences  become  quite  uncertain.  On  that  account,  in  a 
hospital  and  private  practice  of  forty  years,  I  have  seen  only  3 
cases  which,  to  me,  are  conclusive,  but  conclusive  they  are,  for  reasons 
which  I  should  illustrate  in  this  way: 


6l6  CLINICAL  MEDICINE 

If  I  telephoned  from  my  house  in  New  York  to  a  friend  downtown, 
asking  him  to  telegraph  to  a  gentleman  in  Newark,  requesting  him  to 
write  a  letter  to  his  Congressman  at  Washington  about  a  bill  in  Con- 
gress, and  then  report  back  to  me  the  result,  here  telephone,  telegraph, 
and  post-office  would  be  the  analogues  of  my  speech  centers  when  I 
am  reading  aloud  to  somebody.  First,  my  eye  or  reading  center,  would 
then  be  telephoning  to  my  uttering  center,  to  send  its  word  to  my  ears, 
for  them  to  judge  whether  my  eye  center  and  my  uttering  center  were 
each  doing  their  business  correctly.  Now,  the  telephone  might  go 
wrong  from  a  damage  to  it  in  my  own  house,  or  from  a  break  in  the 
wire  between  it  and  the  central  office,  or  from  an  injury  to  the  tele- 
phone receiver  there.  Thus,  we  have  three  kinds  of  telephone  aphasia 
to  begin  with.  Or,  telephone  connections  being  all  right,  there  might 
be  just  the  same  three  kinds  of  derangements  in  the  telegraph  part  of 
the  circuit;  or,  lastly,  telephone  and  telegraph  being  correct,  three 
like  mishaps  might  occur  at  the  post-office,  making  now  nine  distinct 
kinds  of  derangements  of  connection.  But  if  they  are  all  to  work  in 
succession,  with  return  messages  between  them,  there  may  be  three 
times  nine,  or  twenty-seven,  different  possibiHties  of  mishap.  Never- 
theless, and  here  is  the  point,  if  only  a  single  mishap  among  all  the 
possible  mishaps  occurred,  a  careful  investigation  could  finally  locate  it. 
But,  suppose  a  San  Francisco  earthquake  broke  all  telephone  wires  in 
the  place,  wholly  destroyed  the  post-office,  and  left  only  one  telegraph 
wire  in  operation  to  Oakland,  how  much  particular  localization  of  the 
respective  offices  of  these  means  of  communication  could  be  identified 
in  the  upturned  town?  Yet,  that  is  about  what  Marie  attempts 
in  the  majority  of  cases  which  he  reports  of  aphasia  after  apoplectic 
lesions,  which  had  wrecked  not  only  speech  centers,  but  had  damaged 
the  whole  cortical  motor  areas,  in  addition  to  the  ascending  parietal 
kinesthetic  areas,  and  ripped  up  no  one  knows  what  else  between  them 
all. 

My  three  definitely  located  cases  of  aphasia  are  briefly  as  follows : 
First,  a  man  was  brought  to  my  clinic  who  in  a  drunken  row  had  his 
left  eye  poked  at  with  the  sharp  tip  of  an  umbrella,  which,  however, 
instead  of  injuring  his  eye,  passed  over  the  eyeball  and  penetrated  into 
his  brain  through  the  thin  plate  in  the  bony  orbit  on  which  Broca's 
convolution  lies.  He  at  once  lost  all  power  of  speech  utterance  and,  as 
far  as  I  know,  did  not  regain  it  afterward.  He,  however,  could  read 
well  and  understand  every  word  through  his  ears,  so  that,  as  I  was  de- 
scribing his  case  to  my  class,  he  saw  a  student  with  an  umbrella  in  his 
hand,  and  pointing  to  it,  he  burst  into  tears.      Now  in  this  case  there 


APHASIA  617 

was  no  antecedent  disease,  and  the  umbrella  tip  could  not  have  gone 
anywhere  else  than  just  there,  occasioning  but  Uttle  hemorrhage  or 
other  damage. 

The  second  case  was  that  of  a  lady,  who,  without  antecedent  warn- 
ing, was  astonished  to  find  herself  one  morning  as  totally  ilhterate  as 
a  Papuan  savage,  because  she  could  not  read  one  word  in  writing  nor 
a  newspaper  or  book.  When  I  arrived  she  spoke  to  me  as  fluently  as 
any  educated  woman,  and  she  heard  words  as  well  as  ever,  but  until  her 
death  two  years  afterward  she  never  saw  a  word.  I  found,  on  careful 
examination,  no  other  vision  defect,  no  other  sensory  symptom,  and 
absolutely  no  motor  symptom.  She  had  word-blindness  and  nothing 
else. 

The  third  case  was  that  of  a  gentleman,  aged  seventy-six  years,  who 
for  seven  years  had  complete  word-blindness,  along  with  total  inabihty 
to  utter  a  word.  He  came  for  an  opinion  from  me  whether  he  was  com- 
petent to  make  a  will.  He  had  had  his  stroke  of  apoplexy  seven  years 
before,  but  without  the  least  accompanying  sign  of  hemiplegia ;  but  for 
all  these  seven  years,  though  he  could  not  read  nor  write  a  word,  he 
could  read  and  write  arithmetic  figures,  and  by  them  he  had  conducted 
a  large  business,  showing  me  a  memorandum  book  covered  in  his  own 
handwriting  with  records  of  compHcated  monetary  transactions.  No 
one  who  had  dealings  with  him  had  any  doubt  about  his  mental 
capacity.  Now,  the  arithmetic  center  is  as  much  a  speech  center  as 
any  other,  and  he  shows  that  it  must  have  its  own  definite  locaHty; 
also,  his  case  proves  that  if  there  be  no  accompanying  hemiplegia,  then, 
whether  in  a  motor  or  in  a  sensory  aphasia,  no  mental  defect  may 
necessarily  occur. 

One  of  the  common  defects  of  speech  is  that  to  which  the  term 
"paraphasia"  has  been  given.  In  the  slighter  degrees  of  this  derange- 
ment the  patient  uses  words  different  from  those  which  he  intended; 
at  this  stage  he  recognizes  the  difficulty  himself  and  at  once  corrects  it. 
There  can  be  no  doubt  that  the  derangement  here  is  in  the  subcortical 
or  association  fibers,  and  it  is  still  in  that  situation  when  his  trouble 
becomes  so  far  advanced  that  his  talk  is  unintelligible  from  his  constant 
use  of  inappropriate  words.  Ordinarily  speech  itself  is  automatic, 
since  we  do  not  pay  attention  to  each  word  as  we  would  when  we 
imperfectly  know  a  foreign  language;  Hkewise  paraphasia  may  become 
so  pronounced  that  the  patient's  talk  becomes  wholly  confused.  This 
is  analogous  to  the  play  of  the  fingers  on  the  keys  of  the  piano  by  a 
practised  musician,  who  does  not  consciously  note  each  stroke  which 
he  makes.     Similarly,  the  motor  speech  mechanisms  in  the    brain 


6i8  CLINICAL   MEDICINE 

are  called  into  play  without  attention  being  given  to  each  word  as  it 
is  articulated. 

As  it  is  by  the  association  fibers  that  the  different  elements  in 
speech  are  properly  co-ordinated,  so  a  lesion  of  these  fibers  may  easily 
produce  paraphasia  instead  of  true  aphasia. 

Other  specific  derangements  of  speech  may  occur  in  which  whole 
classes  of  words  are  lost.  A  man  once  came  to  my  clinic  who  could  not 
utter  a  word,  though  he  could  understand  whatever  was  spoken  to 
him;  on  examination,  I  concluded  that  his  trouble  was  due  to  the 
pressure  of  a  syphilitic  gumma  on  his  motor  speech  center.  On  having 
him  removed  from  the  room,  so  that  he  could  not  hear  what  I  said,  I 
told  the  class  that  we  would  cure  his  difiicalty  of  speech  by  iodid  of 
potassium,  and  that  he  would  recover  his  speech  m  the  following  order: 
first,  he  would  get  his  pronouns,  then  his  verbs,  and  last  of  all  his 
nouns.  Accordingly,  on  the  following  Friday  clinic  he  was  able  to  use 
his  pronouns  and  also  his  verbs,  but  not  yet  his  nouns.  Then,  showing 
him  a  pen,  he  answered,  "you  write  with,"  and  a  knife,  "you  cut  with." 
The  following  week  he  had  recovered  all  his  nouns.  I  then  told  the 
class  that  during  his  difiiculty  he  could  use  words  under  emotion  and 
even  sing  them,  whereupon  he  interrupted  me  by  saying,  "yes,  pro- 
fessor, when  I  could  not  speak  I  still  could  'cuss'  like  the  devil,  and 
could  sing  'Rally  Round  the  Flag  Boys.'  "  The  reasons  were  that 
verbs  are  subjectively  deeper  and  earlier  learned  than  nouns.  It  is 
we  who  hear  or  see  or  feel  before  we  know  what  it  is  we  hear  or  see  or 
feel.  Nouns,  therefore,  are  names  given  to  objects  outside  of  us,  and 
are  hence  last  learned  and  the  first  to  be  forgotten,  as  is  familiarly  the 
case  with  proper  names. 

A  child  who  has  learned  to  speak  may  become  aphasic  by  an  embolus 
reaching  his  brain  from  a  growth  on  a  heart  valve.  Many  cases  of  the 
kind  have  been  reported  in  which  the  children  afterward  learned 
to  speak  by  teaching  the  corresponding  centers  of  the  other  hemi- 
sphere. One  case  is  reported  where,  after  injury  had  occurred  in  one 
hemisphere,  a  similar  injury  occurred  in  the  corresponding  hemisphere, 
with  the  result  of  permanent  aphasia.  In  adults,  however,  such  vascu- 
lar lesions  usually  happen  only  after  middle  life,  when  the  speech 
layers  are  no  longer  teachable.  In  some  cases,  by  beginning  to  learn 
as  they  would  in  childhood,  by  constant  repetition  of  familiar  words, 
some  ability  to  speak  has  been  recovered.  It  is  curious  that  in 
sight  aphasia  the  letters  of  a  printed  word  are  sooner  learned  than 
the  words  themselves,  so  that  they  have  to  spell  the  words  first  before 
they  can  pronounce  them.    In  many  cases  the  derangement  is  evidently 


HYDROCEPHALUS  619 

functional  and  not  organic,  or  the  joatients  may  remain  aphasic  for  only 
a  week,  and  then  gradually  recover  their  powers  of  speech. 

INFLAMMATION  OF  THE  BRAIN   (ENCEPHALITIS) 

Encephalitis,  or  inflammation  of  the  brain  substance,  is  usually 
difficult  of  diagnosis  as  such.  It  is  often  traumatic  and  following 
upon  puncture  of  the  skull,  which  then  injures  the  membranes  and  par- 
ticularly the  dura  mater.  It  also  occurs  in  severe  infections,  which 
may  produce  cerebral  inflammations,  just  as  they  produce  localized 
inflammations  in  other  organs.  In  such  cases  the  symptoms  may  not 
be  localizing  or  focal,  so  that  they  have  often  been  mistaken  for  ty- 
phoid fever.  The  commonest  cause  of  encephalitis  is  from  extension 
of  cerebrospinal  inflammation,  particularly  when  exudations  at  the 
base  of  the  brain  involve  the  organs  of  the  special  senses.  In  my 
own  experience,  a  common  cause  is  from  sunstroke,  when  the  result- 
ing symptoms  may  be  chronic. 

Treatment. — The  treatment  in  such  cases  is  similar  to  that  of  in- 
flammations following  the  course  of  the  specific  fevers,  unless  definitely 
focal  symptoms  can  be  recognized.  In  one  case  of  my  own  the  symp- 
toms during  life  were  those  of  a  furious  mania,  which  in  a  few  days 

terminated  in  death. 

HYDROCEPHALUS 

The  appearance  of  a  child  with  chronic  hydrocephalus  is  unmis- 
takable. Rising  above  the  small  face  is  a  greatly  expanded  skull  in 
all  directions,  but  especially  in  the  frontal  region,  which  may  bulge 
over  the  face,  sometimes  with  protrusion  of  the  eyeballs.  The  natural 
sutures  of  the  skull  are  all  separated,  and  the  fontanels  widened  in 
every  direction.  All  these  features  are  due  to  accumulation  of  a  drop- 
sical fluid  in  the  lateral  ventricles,  the  mechanism  of  which  is  obscure, 
occurring  from  below  upward.  The  cortex  of  the  cerebrum  is,  there- 
fore, spread  out,  and  all  its  numerous  folds  or  sulci  obliterated.  In 
t)^pical  cases  of  this  kind  the  disease  is  not  only  congenital,  but  fre- 
quently prenatal,  belonging,  therefore,  to  defect  in  development,  of 
which  we  have  no  explanation. 

The  clinical  symptoms  are  plainly  due  to  the  mechanical  effect  of 
the  dropsical  accumulation.  In  some  children  the  intelligence  seems 
to  be  nearly  normal,  but  the  rule  is  that  they  soon  succumb  to  com- 
plications caused  by  mechanical  interference  of  the  growth  of  the 
body. 

Another  form  of  hydrocephalus  is  called  acquired,  to  distinguish 
it  from  the  congenital.     This  form  may  develop  later  in  life,  and  is 


620  CLINICAL  MEDICINE 

usually  caused  by  the  presence  or  growth  of  a  tumor  situated  ordinarily 
in  the  third  ventricle.  As  we  have  remarked  in  speaking  of  brain 
tumors,  these  cases  are  accompanied  by  headaches  and  other  signs  of 
intracranial  pressure,  producing  optic  neuritis  and  blindness.  The 
real  condition  of  the  patient  may  not  be  diagnosed  during  life,  but 
after  death  the  ventricles  are  found  greatly  distended  from  pressure 
upon  the  local  veins,  which  are  sometimes  much  dilated. 

Treatment. — ^We  have  no  proper  treatment  for  this  condition. 
Attempts  have  been  made  to  reduce  the  intercranial  effusion  by  lumbar 
puncture  so  as  to  tap  the  cerebrospinal  canal,  but  so  far  nothing  but 
disastrous  results  have  followed  this  operation. 

BRAIN  TUMORS 

Intercranial  or  other  brain  tumors  have  certain  clinical  features 
which  are  very  characteristic.  These  are:  first,  headache,  which  may 
be  either  frontal  or  occipital;  second,  vomiting;  and,  lastly,  choked 
disk,  which  is  due  to  an  edema  of  the  optic  nerve.  These  signs  when 
taken  together  almost  certainly  tell  of  brain  tumors,  but  they  do  not 
indicate  the  nature  of  the  tumors  nor  their  locations.  The  situation 
may  be  all  important  because  of  the  great  advance  made  in  recent 
years  in  the  surgery  of  the  brain. 

Masses  of  tubercles  may  form  actual  tumors  in  the  brain,  usually 
secondary  to  tuberculosis  elsewhere,  but  sometimes  found  only  in  the 
brain  substance,  chiefly  in  children  or  in  young  subjects.  Syphiloma 
may  also  develop  in  the  cortex  or  at  the  base  of  the  brain  about  the 
pons.  GUoma  is  one  of  the  most  common  tumor  formations  of  the 
brain.  It  may  be  hard,  almost  Uke  an  area  of  sclerosis,  and  not  sharply 
defined  from  the  surrounding  brain  substance.  Developing  in  the 
neighborhood  of  the  pituitary  body,  it  is  very  likely  to  produce  blind- 
ness from  optic  neuritis.  Gliomatous  tumors  may  be  quite  vascular 
and  produce  local  hemorrhages. 

Brain  tumors  are  of  varied  nature,  some  of  them  being  true  fibro- 
sarcomata,  and,  developing  in  the  cortex,  may  give  rise  to  decided  focal 
symptoms,  which  will  greatly  aid  in  their  topical  diagnosis,  and  thus 
assist  the  surgeon  when  operating  for  their  removal. 

Cancerous  tumors  of  the  brain  are  always  secondary  to  cancer 
elsewhere,  particularly  about  the  cecum  or  colon.  In  some  cases  of 
cerebral  tumors  a  spot  tender  to  pressure  may  be  found  on  the  skull. 
Bony  outgrowths  from  the  falx  may  also  occur,  one  of  which  was  nearly 
one  inch  in  length  in  a  patient  of  mine  who  died  from  convulsions. 
Fibroid  tumors  may  also  develop  from  the  dura.     Cystic  formations 


ABSCESS    OF   THE   BRAIN  62 1 

may  sometimes  be  found  as  a  result,  usually,  of  injuries,  producing 
subdural  hemorrhage. 

We  have  already  alluded  to  that  variety  of  sarcomatous  tumors 
called  psammoma,  in  which  after  death  the  brain  is  found  simply  infil- 
trated with  gritty  particles  of  carbonate  of  lime. 

Brain  tumors  often  produce  true  focal  symptoms,  which  have  en- 
abled surgeons  to  perform  some  of  their  most  noted  operations. 

SyphiUtic  tumors  of  the  brain  cannot  be  diagnosed  apart  from  the 
manifestation  of  syphilis  elsewhere,  but  when  a  patient  shows  the 
signs  of  brain  tumors,  such  as  headache  and  optic  neuritis,  a  free  course 
of  potassium  iodid  may  be  hoped  to  remove  all  the  symptoms. 

ABSCESS  OF   THE  BRAIN 

The  symptoms  of  abscess  of  the  brain  may  be  very  suggestive  of 
the  presence  of  this  lesion,  or  they  may  be  the  most  obscure  of  any 
brain  symptoms.  I  can  hardly  forgive  myself  for  being  misled  by 
the  statements  of  the  attending  physician  who  ascribed  the  obstinate 
taciturnity  of  a  young  lady  to  hysteria,  as  he  told  me  that  she  had  often 
before  been  very  hysteric.  Besides  myself,  an  eminent  consultant 
had  been  called  in,  who  fully  agreed  with  the  diagnosis  of  hysteria. 
While  we  all  three  were  yet  in  the  house  the  patient  suddenly  died. 
I  then,  for  the  first  time,  learned  that  she  had  been  subject  to  chronic 
otitis  media,  and  that  the  discharge  from  her  ear  had  ceased  for  over  a 
month. 

There  is  no  cause  of  brain  abscess  so  common  as  chronic  otitis. 
Next  in  frequency  are  suppurative  conditions  of  the  mastoid  cells, 
as  most  cases  of  these  are  preceded  by  otitis.  It  should  be  remem- 
bered that  in  the  upper  part  of  the  cavity  of  the  tympanum  is  the 
thinnest  bone  in  the  body,  itself  not  much  larger  than  the  surface  of  a 
split  pea.  On  the  brain  aspect  of  this  thin  piece  of  bone  there  is  usu- 
ally a  good-sized  vein  which  communicates  with  the  lateral  sinus. 
Inflammations  of  the  middle  ear,  therefore,  may  excite  a  septic  throm- 
bosis of  this  vein,  which  soon  involves  the  contiguous  structures,  and 
affords  an  explanation  of  the  penetration  into  the  brain  substance  of 
septic  organisms  with  the  attendant  formation  of  a  brain  abscess  in 
the  temporal  lobe.  The  symptoms  of  such  an  abscess  may  then  be 
severe  headache,  with  signs  according  to  the  acute  or  chronic  develop- 
ment of  the  abscess.  The  abscess  does  not  often  produce  optic  neuritis, 
and  thus  differs  from  brain  tumors.  Instead,  there  is  fever  or  a  very 
suspicious  symptom,  which  is  an  irregular  and  intermittent  pulse.  In 
every  case  presenting  such  symptoms  the  condition  of  the  ear  should  be 


62  2  CLINICAL   MEDICINE 

carefully  investigated,  particularly  as  in  modem  times  it  is  well  known 
that  the  brain  can  be  examined  by  surgical  procedures  with  impunity. 

NEUROMATA 

These  are  tumors  forming  upon  nerves  in  their  course,  and  are 
generally  due  to  congenital  faults  in  development.  Some  of  these 
tumors  resemble  gHomata  in  their  structure,  but  others  contain  true 
nerve-fibers,  and  a  few  have  actual  ganglionic  cells.  In  other  cases 
they  resemble  plexuses.  Neuromata  sometimes  occur  in  great  num- 
bers on  the  surface  of  the  body,  and  can  be  easily  felt  under  the 
skin.  Occasionally  they  involve  sensory  nerves,  so  as  to  become  quite 
painful,  requiring  surgical  removal.  We  should  clearly  distinguish 
from  neuromata  the  formation  of  bulbous  outgrowths  at  the  ends  of 
nerves  in  amputations.  These  are  usually  very  painful,  but  the  patients 
refer  the  pain  to  the  ends  of  the  amputated  limbs.  I  knew  of  a  case 
who  couldn't  be  persuaded  that  his  amputated  leg  was  not  before  him 
on  the  carpet,  due  to  the  fact  that  all  injuries  to  a  nerve  in  its  course  in 
health  are  referred  always  to  the  periphery;  as  when  the  funny  bone  is 
struck  at  the  elbow,  the  pain  is  not  felt  there  at  the  point  of  injury,  but 
at  the  ends  of  the  ulnar  nerves  in  the  fingers. 

The  only  treatment  for  such  cases  is  to  dissect  up  the  implicated 
nerve  bulb  involved  in  the  amputation,  removing  it  from  the  retracted 
flap. 


CHAPTER  XXI 

DISEASES  OF  MUSCLES 
INTRODUCTION 

Of  all  the  chief  textures  of  the  body,  the  muscles  are  the  least  likely 
to  be  the  seat  of  special  disease.  This  is  remarkable  when  we  consider 
the  great  importance  of  the  muscular  tissues  in  their  relations  to  life. 
Thus,  as  we  have  remarked  in  diabetes  mellitus,  the  muscles,  besides 
their  other  functions,  are  the  true  furnaces  of  the  body,  as  it  is  in  them 
chiefly  that  the  carbohydrates,  whether  starches  or  fats,  are  literally 
burned  up,  ending  in  carbonic  acid,  like  any  stick  of  wood  or  other 
combustible  article.  This  heating  function  of  the  muscles  is  altogether 
independent  of  their  contraction  and  relaxation  by  which  all  bodily 
movements  are  executed,  for  the  muscles  generate  heat  while  they  are 
at  perfect  rest.  It  is  fortunate  for  us,  therefore,  that  of  all  the  im- 
portant tissues  of  the  body,  true  muscular  disease  is  so  uncommon.  So 
intimate  is  the  relation  of  all  muscles  to  the  nerves  which  activate  them 
that  it  is  difficult  to  treat  muscular  disorders  without  alluding  to 
the  connections  of  the  muscles  with  the  nervous  system.  But  such 
disorders  do  take  place  in  which  the  muscles  only  are  involved.  These 
diseases  are  purely  and  primarily  muscular,  and  not  due  to  any  changes 
in  the  cerebrospinal  axis,  the  muscles  presenting  no  fibrillary  twitchings, 
but  simply  wasting  away,  with  sometimes  deposits  of  fat  taking  place 
between  the  atrophied  muscle  bundles.  This  fatty  increase  may  so 
mask  the  muscular  wasting,  especially  in  the  calves  of  the  legs,  as  to 
cause  those  parts  to  be  apparently  h3^pertrophied.  In  other  cases 
there  is  no  deposit  of  fat,  but,  instead,  all  true  muscular  structure  dis- 
appears. 

These  muscular  affections  vary  in  their  symptoms  according  to  the 
groups  of  muscles  implicated.  They  are,  as  a  rule,  unaccompanied 
with  any  sensory  disturbances,  and  in  the  great  majority  of  cases  are 
due  to  hereditary  defects  in  muscular  growth;  these  affections  occurring, 
on  that  account,  in  families  as  part  of  the  congenital  structural  devel- 
opment of  the  muscular  system. 

MYOSITIS 

Of  these  disorders,  we  have  myositis,  or  inflammation  of  muscles 
proper,  reported  only  from  a  comer  of  Japan,  which  is  ascribed  to  bac- 

623 


624  CLINICAL  MEDICINE 

terial  infection  causing  actual  suppuration,  the  agents  of  which  are  the 
familiar  Staphylococcus  pyogenes  and  the  Streptococcus  pyogenes. 
Sometimes  infection  occurs  from  the  skin  and  proceeds  inward,  and  is 
then  called  dermatomyositis. 

MYOTONIA,  OR  THOMSEN'S  DISEASE 

Another  imcommon  affection  is  called  myotonia,  or  Thomsen's  dis- 
ease, rare  in  every  coimtry  except  Germany  and  Scandinavia.  In  this 
complaint  the  spinal  cord  and  its  nerves  are  intact,  but  the  voluntary 
muscles  show  a  peculiar  stiffness,  particularly  at  the  beginning  of  a 
muscular  act.  This  disease  begins  in  very  early  Hfe,  and  is  restricted 
to  the  few  famiHes  in  which  it  occurs  as  a  hereditary  trouble. 

MYASTHENIA  GRAVIS 

In  this  affection  the  spinal  cord  and  nerves  are  found  intact,  but 
all  the  volimtary  muscles  are  soon  fatigued  instead  of  being  para- 
lyzed. That  they  are  not  paralyzed  is  shown  by  their  temporary 
recovery  or  power  after  rest.  It  is,  however,  a  grave  complaint,  for, 
of  the  recorded  cases,  it  proved  fatal  in  about  45  per  cent.  In  some 
cases  the  affection  is  temporary,  patients  recovering  and  living  to  old 
age. 

Treatment,  therefore,  should  not  be  omitted,  and  consists  of  mas- 
sage, faradism  stopping  short  of  fatigue,  the  use  of  strychnin,  and  the 

iodids. 

FRIEDREICH'S  DISEASE 

Friedreich's  disease  is  usually,  but  not  always,  a  hereditary  com- 
plaint, characterized  by  sjrmptoms  not  unlike  those  of  tabes  dorsahs, 
but  differing  altogether  from  that  complaint  in  respects  of  the  age  and 
the  characters  of  the  muscular  inco-ordination.  Thus,  in  Griffith's 
143  cases  the  majority  were  in  the  early  period  of  life,  all  except 
5  occurring  before  the  twentieth  year,  15  occurring  before  they  were 
two  years  old. 

As  to  s3nnptoms  the  inco-ordination  resembles  sometimes  that  of  a 
drimken  man,  and  not  the  stamping  walk  of  the  tabetic,  and  very 
marked  ataxia  occurs  early,  in  distinction  from  tabes  in  the  arms. 
The  movements  of  the  affected  limbs  are  so  irregular  that  they  even 
resemble  chorea.  It  differs  from  chorea,  however,  in  that  the  hand 
seems  to  hover  over  the  object  aimed  at  and  suddenly  pounces  upon  it. 
There  are  also  irregular  movements  of  the  head  and  body. 

The  deep  reflexes  are  early  lost,  the  skin  reflexes  are  normal  and 
so  are  those  of  the  pupils,  but  there  is  pronounced  nystagmus.     The 


MYALGIA  625 

speech  is  also  affected  and  is  scanning  in  character.  Sensory  derange- 
ments are  rarely  present. 

The  feet  become  early  distorted  and  talipes  equinus  is  common,  the 
big  toe  is  flexed,  and  scohosis  or  distortion  of  the  spine  is  often  present. 

Morbid  anatomy  shows  disease  of  the  posterior  columns,  as  in 
tabes,  but  evidently  of  different  origin,  because  the  neuroglia  are 
implicated,  as  if  the  affection  were  really  a  gliosis,  involving  especially 
the  cerebellar  tract,  thus  explaining  the  irregular  movements. 

There  is  a  cerebellar  type  of  this  disease  which  is  markedly  hered- 
itary, but  which  starts  later  in  hfe,  after  the  age  of  twenty.  In  this  case 
the  knee-jerks  are  retained  and  a  spastic  condition  of  the  legs  ultimately 
develops.     The  cerebellum  has  been  found  atrophied  in  2  cases. 

Friedreich's  disease  is  practically  incurable,  and  as  it  advances 
complete  paralysis  may  come  on. 

MYALGIA 

A  word  may  be  said  here  about  a  very  common  complaint,  myalgia, 
which  means  pains  referred  to  the  tendinous  attachments  of  weakened 
muscles;  in  fact,  indicative  simply  of  muscular  overstrain.  Thus,  it 
is  quite  common  among  women  to  complain  of  pain  along  the  attach- 
ments of  the  abdominal  muscles  to  the  lower  ribs.  Other  cases  have 
aching  pain  at  the  nape  of  the  neck,  due  to  the  inabiUty  of  the  weak- 
ened spinal  muscles  to  bear  the  weight  of  the  head.  Many  of  these 
cases  suffer  from  pain  in  the  eyes.  Other  cases  are  characterized  by 
aches  and  pains  along  the  whole  spinal  colxmin,  all  due  to  the  overtaxing 
of  the  debilitated  muscles  that  maintain  the  body  in  its  erect  posture. 
The  spinal  muscles,  in  fact,  may  be  so  weakened  and  aching  that  the 
spinal  column  becomes  distorted,  usually  between  the  shoulders,  from 
the  habit  of  patients  throwing  the  weight  in  standing  on  the  right  leg. 
The  processes  of  the  vertebrae  may,  therefore,  become  tender  to  touch. 
This  disease  should  never  be  considered  in  any  way  inflammatory,  no 
matter  how  much  the  pains  may  be  complained  of. 

Treatment. — The  proper  treatment  is  by  repeated  rest,  the  patient 
remaining  recumbent  for  an  hour  or  so,  and  then  rising,  while  cold 
sponging  to  the  spine,  followed  by  friction,  should  be  performed  night 
and  morning.  Rest  in  the  open  air,  lying  down  in  a  hammock,  is  to  be 
advised,  on  the  principle  that  nothing  so  strengthens  muscles  as  a  free 
supply  of  oxygen,  while  all  means  for  improving  general  nutrition 
should  be  systematically  observed. 

Equal  parts  of  cologne  and  vinegar,  appUed  warm  to  the  aching 
parts,  are  very  effective. 

40 


CHAPTER  XXII 

MALIGNANT  DISEASES 

INTRODUCTION  TO  THE  STUDY  OF  NEW  GROWTHS 

There  is  no  more  remarkable  organization  in  the  world  than  a 
healthy  human  body.  Every  part  in  it  takes  its  own  proper  place  for 
the  purpose  of  mutual  well  being.  Neither  cell  nor  tissue  exists  for  its 
own  sake,  but  rather  for  the  benefit  of  the  entire  organism.  Not  only 
can  the  hand  say  to  the  foot,  'T  have  no  need  of  thee,"  but  every- 
thing in  the  body  exists  for  the  purpose  of  ministering  to  the  advantage 
of  the  rest.  Meantime  the  cells  of  every  tissue  of  the  body  have 
the  property  of  growth  and  of  multipHcation.  This  is  shown  by  small 
cutaneous  grafts  when  implanted  on  a  non-healing  ulcerated  surface 
of  the  skin.  These  grafts  begin  to  grow  in  all  directions,  their  cells 
making  the  true  skin  until  they  meet  the  edges  of  healthy  skin,  when 
they  at  once  cease  to  proceed  further. 

One  pecuHarity  in  these  growing  cells,  as  they  form  new  skin,  is 
that  before  reaching  the  borders  of  healthy  tissue  the  latter  begins  to 
throw  out  growths  to  meet  the  approaching  cells  of  the  new  skin. 
This  seems  to  indicate  that  an  invisible  influence  is  at  work  to  direct 
the  new-growing  cells,  a  fact  which  is  not  without  its  bearing  upon  all 
healthy  nutrition,  and  it  may  be  the  absence  of  this  influence  which  will 
explain  some  of  the  features  of  malignant  growths.  If  they  did  proceed 
further,  they  would  then  become  new  growths.  There  is,  therefore,  no 
room  in  the  body  for  anything  really  new.  A  tumor,  even  if  only  a 
small  wart,  is  out  of  place,  a  truth  illustrated  by  the  fact  that  warts, 
and  particularly  moles,  are  often  the  beginnings  of  very  injurious  or  so- 
called  mahgnant  growths,  so  much  so  that  many  surgeons  recommend 
that  every  wart  should  be  removed  by  total  excision. 

New  growths,  therefore,  are  always  to  be  regarded  as  entirely  out 
of  place,  and  pathologists  all  over  the  world  are  diligently  investigating 
the  causes  of  them.  Their  reasons  for  so  doing  are  that  no  one  can 
tell  at  what  time  or  turn  a  really  new  growth  may  not  be  the  begin- 
ning of  the  end  in  a  terrible  death.  This  happens  when  a  new  growth 
takes  on  the  characters  called  mahgnant.  These  growths,  instead  of 
ministering  in  any  way  to  the  general  wefl-being  of  the  body,  are  dis- 

626 


INTRODUCTION    TO    THE     STUDY    OF    NEW     GROWTHS  627 

tinctly  injurious  from  the  start.  Thus,  instead  of  behaving  with  a 
strict  regard  to  the  rights  of  its  neighbors,  a  malignant  sarcoma,  for 
example,  grows  quite  independently,  invading  its  neighbors  so  rapidly 
that  it  destroys  them  by  its  own  unchecked  multiplication.  Some 
sarcomata  simply  play  havoc  wherever  they  spread,  and  may  extend 
along  the  lymphatics,  to  set  up  new  centers  of  development  having  all 
the  evil  characters  of  the  growth  from  which  they  started.  Another 
serious  feature  in  them  is  that  they  often  seem  to  secrete  poisons  which 
devitalize  and  destroy  the  healthy  tissues  they  invade,  including  the 
blood.  I  had  a  patient  some  sixty  years  of  age  who  was  remarkable 
for  his  good  looks.  He  began  to  complain  of  a  locahzed  pain  in  his 
sacrum.  At  once  he  showed  loss  of  color,  and  soon  after  a  progressive 
loss  of  flesh.  In  the  course  of  eighteen  months  he  was  a  mere  shadow 
of  his  former  self,  and  yet  not  at  all  from  lack  of  food,  for  he  never  lost 
his  appetite,  and  apparently  digested  well  whatever  he  took.  When 
he  died  I  made  a  necropsy,  and  found  only  a  small  cancerous  tumor  in 
his  prostate,  with  a  few  enlarged  lymphatic  glands  leading  from  it, 
and  another  small  secondary  tumor  involving  the  root  of  the  first  an- 
terior sacral  nerve,  which  explained  his  pain.  Above  this  were  a  few 
cancerous  nodules  in  his  liver,  but  altogether  these  new  growths  did  not 
weigh  an  ounce,  and  yet  were  sufficient  to  make  him  appear  as  if  he 
were  stricken  by  some  cruel  fiend. 

The  evil  effects  of  malignant  growths,  where  they  attain  any  size, 
are  illustrated  by  the  term  "cancerous  cachexia,"  by  which  is  meant 
a  systemic  decline  in  health  marked  by  special  characteristic  features. 

Though  originally  so  difficult  to  account  for,  tumors  may  be  of 
widely  different  characters.  Some  of  them  seem  to  be  simple  over- 
growths of  the  tissues  in  which  they  develop.  Such  are  the  so-called 
myomata,  which  are  made  up  chiefly  of  healthy  normal  muscle  tissues. 
These  are  frequent  in  the  body  of  the  uterus,  and  may  occasion  no  in- 
convenience nor  tendency  to  shorten  life.  To  this  class  the  term 
''benign"  has  been  given,  meaning  that  they  show  no  tendency  to 
infiltrate  neighboring  tissues,  but,  at  most,  simply  to  displace  them. 
Malignant  tumors,  on  the  other  hand,  are  characterized  by  their  inde- 
pendence of  afl  check  or  rule.  To  this  independence  the  technical 
term  "anaplasia"  has  been  given.  Thus,  all  cancers  and  sarcomata  are 
virtually  like  parasites,  which,  invading  the  body,  then  grow  as  they 
please,  and  reproduce  themselves  precisely  as  they  began,  without  any 
reference  to  the  advantage  of  the  organism. 

Unfortunately,  there  seems  to  be  no  limit  to  the  development  of 
malignant  growths  in  the  vertebrate  animal  kingdom.     Wild  animals 


628  CLINICAL  MEDICINE 

in  the  state  of  nature,  and  domesticated  animals,  whether  cattle,  horses, 
swine,  or  even  fishes,  develop  cancer  as  well  as  man. 

The  only  encouraging  feature  is  that  these  growths  generally  begin 
as  purely  local  developments,  so  that  if  they  can  be  entirely  removed 
at  this  stage  they  do  not  return.  Thus,  one  of  the  most  serious  of 
them  is  cancer  of  the  stomach,  but  it  has  been  frequently  shown  that  if 
gastric  cancer  can  only  be  recognized  in  time,  the  surgeon  can  excise  it 
and  thus  effect  a  permanent  cure. 

In  such  cases,  however,  it  is  not  the  tumor  that  is  cured,  but  the 
patient. 

One  of  the  worst  features  of  specifically  malignant  new  growths  is 
their  tendency  to  metastasis,  by  which  term  is  meant  that  the  specific 
germs  of  the  disease  are  detached  from  the  new  growth  itself,  and 
carried  either  by  the  lymphatics  or  by  the  blood  to  distant  localities, 
where  they  grow  again  with  all  their  special  features  down  to  the 
smallest  anatomic  details.  Thus,  a  carcinoma  in  the  rectum  may  be 
the  source  of  a  secondary  tumor  in  the  brain,  which,  if  examined,  is 
found  to  consist  of  the  special  squamous  cells  which  line  the  mucous 
membrane  of  the  descending  colon.  To  this  important  feature  of 
malignant  growth  the  term  "autositic"  has  been  given.  It  is  one  of 
the  evidences  of  the  essentially  foreign  origin  of  malignant  growths 
that  whenever  such  tumors  are  found  in  the  body  the  question  at 
once  arises  as  to  the  location  of  the  primary  seat  of  the  invader. 

The  property  of  giving  rise  to  metastasis  does  not  belong  to  all 
mahgnant  growths.  Thus,  there  are  certain  tumors  which  may  infil- 
trate the  surrounding  tissues,  and  which,  if  they  reach  the  skin,  ul- 
cerate and  fungate,  sometimes  forming  masses  of  considerable  size, 
but  which  do  not  give  rise  to  secondary  growths  in  distant  glands 
or  in  distant  organs.  Rodent  ulcer,  for  example,  among  the  epithelial 
tumors,  belongs  to  this  group. 

Mahgnant  tumors  are  usually  divided  into  two  classes — carcino- 
mata  or  cancers,  which  spring  from  epithelial  tissues;  and  sarcomata, 
which  spring  from  connective  tissue. 

In  the  case  of  carcinomata,  particularly,  the  presence  of  a  cancerous 
deposit  leads  to  an  increase  of  connective  tissue  about  it,  which  is 
usually  very  firm,  and  in  cancer  of  the  breast  forms  a  hard  lump,  to 
which  the  term  "scirrhus"  has  been  given. 

Malignant  tumors,  whether  slow  or  rapid  in  their  growth,  appear 
to  have  a  limited  vitality  compared  to  the  cells  of  normal  tissue,  and, 
therefore,  in  time  break  down  and  form  large  ulcers.  The  secretion 
of  these  ulcers  often  has  a  very  offensive  odor,  as  if  due  to  actual 


INTRODUCTION    TO    THE    STUDY    OF    NEW    GROWTHS  629 

necrosis  or  death  of  the  tissue.  The  modes  of  this  degeneration  are 
quite  various  in  different  cases.  In  the  stomach,  for  example,  there 
is  a  frequent  tendency  to  what  is  called  colloid  degeneration.  I  have 
known  of  a  case  in  which  the  stomach  was  more  than  half-filled  by 
what  appeared  to  be  a  tumor  of  simple  colloid,  without  any  cancerous 
element  apparent.  In  a  sense,  however,  the  term  "colloid"  is  a  mis- 
nomer, for  the  substance  has  no  resemblance  to  true  colloid,  as  it  is 
found  in  the  cells  of  the  thyroid  gland,  and,  instead,  seems  to  be  a 
modification  of  the  mucin  secreted  by  a  mucous  membrane.  Hence,  it 
is  not  uncommon  to  find  the  same  kind  of  degeneration  occurring  in 
cancers  of  the  intestinal  tract. 

The  second,  and  perhaps  more  common  form  of  degeneration,  is 
fatty  metamorphosis,  which  is  itself  a  natural  termination  of  imperfect 
growth.  In  such  cases  the  true  cancer  cells  may  be  found  only  at  the 
periphery  of  the  growth. 

Another  degeneration  is  that  in  which  the  tissue  is  transformed 
into  a  mucin-like  body.  This  is  particularly  common  in  some  forms  of 
sarcoma,  so  that  they  are  called  myosarcomata. 

Hyalin  degeneration  is  another  form,  called  so  from  its  appearance, 
being  a  homogeneous,  structureless  substance  characterizing  the  whole 
tumor,  or  found  scattered  only  here  and  there  through  its  substance. 

Lastly,  there  is  a  fibroid  change  which  in  places  gives  rise  to  de- 
posits of  lime  salts.  It  is  curious  that  these  may  at  times  resemble  the 
structure  of  bones,  and  in  some  metastases  actual  formation  of  bony 
tissue  may  occur. 

Theories  as  to  the  origin  and  nature  of  malignant  growths  are  nu- 
merous, bu^  none  of  them  has  as  yet  been  generally  accepted  among 
pathologists.  Among  them  is  Cohnheim's  theory,  which  virtually  is, 
that  at  certain  times  during  the  development  of  the  embryo  some  cells 
become  detached  from  the  parent  organism,  and  then  may  rest  in  the 
body,  not  to  develop  into  new  growths  perhaps  for  years.  This  inge- 
nious theory,  however,  lacks  the  facts  which  would  demonstrate  it,  and, 
therefore,  is  now  generally  discredited.  A  more  probable  supposition 
is  that  of  Ribbert,  who  postulates  something  like  an  antecedent  in- 
flammatory process,  occurring  in  what  he  calls  the  precancerous  stage. 
This  process  lifts,  as  it  were,  a  set  of  cells  from  their  previous  attach- 
ment and  sets  them  free,  to  live  an  independent  existence.  There 
can  be  no  doubt  that  the  theory  of  a  precancerous  stage  has  something 
to  recommend  it,  but,  if  so,  it  should  give  some  sign  of  its  presence  in 
the  very  earliest  steps  of  a  malignant  growth,  which  is  by  no  means  the 
case. 


630  CLINICAL  MEDICINE 

A  very  general  view  held  at  present  is  that  the  cells  of  a  mahgnant 
growth  are  simple  modifications  of  normal  cells  which  have  taken  on 
malignant  properties  by  as  yet  miknown  processes.  The  chief  argu- 
ments for  this  view  are  that  maUgnant  growths  often  develop  in  tissues 
where,  at  the  beginning,  it  is  difficult  to  show  in  what  respects  they 
differ  at  all  from  the  normal  tissues  in  which  they  are  found.  This 
view  was  naturally  suggested  by  the  failure  to  find  any  unmistakable 
parasitic  organism  to  which  they  could  be  ascribed,  such  as  we  find 
as  the  specific  causes  of  the  majority  of  infectious  agents,  as,  for 
example,  the  tubercle  bacillus.  My  own  view  is  that  the  characteristic 
cell,  whether  of  a  carcinoma  or  sarcoma,  is  itself  a  parasite,  and  con- 
tains all  the  properties  of  a  true  parasite.  How  it  originates  is  yet 
unknown,  but  that  it  is  a  modification  of  any  normal  cell  is  to  me  im- 
probable. The  chief  argument  that  it  is  not  a  foreign  parasitic  organ- 
ism is  that  in  nearly  all  cases  of  true  parasites  they  are  specific.  Thus, 
the  bacillus  of  typhoid  fever  can  grow  only  in  a  human  body,  but 
against  this  the  tubercle  bacilli  can  grow  in  the  bodies  of  not  only  the 
warm-blooded,  but  also  in  the  cold-blooded,  animals.  On  the  other 
hand,  experiments  have  shown  that  malignant  tumors  may  be  trans- 
ferred from  one  mouse  to  the  other,  and  even  be  sent  by  mail,  as  Jen- 
sen did  from  Copenhagen  to  London,  although  such  growths  cannot  be 
transferred  except  to  animals  of  the  same  species.  One  hopeful  result 
of  these  experiments  was  that,  although  cancer  cells  might  be  trans- 
ferred to  rats  from  mice,  yet  in  the  rat  the  growths  soon  aborted, 
and  that  after  a  rat  recovered  he  became  immune  to  any  further  im- 
plantation of  cancer  from  mice. 

A  more  probable  clue  to  the  origin  of  malignant  growths  is  found 
in  the  investigations  of  the  development  and  changes  that  occur  in  the 
nuclei  of  living  cells.  It  is  now  generally  admitted  that  the  nucleus 
is  the  most  living  part  of  a  cell.  It  shows  a  most  complicated  arrange- 
ment of  its  constituent  particles,  and  that  it  is  in  the  nucleus  that  all 
hereditary  potencies  are  contained.  In  normal  growth  the  nucleus 
begins  by  dividing  into  two  symmetric  halves,  which  contain  a  definite 
number  of  special  constituents  called  chromosomes,  and  named  ac- 
cording to  their  shapes  and  destinations.  Each  of  the  two  daughter- 
cells  which  follow  upon  the  division  of  the  nucleus  should  contain 
exactly  the  same  number  and  kind  as  those  of  the  parent  cell,  but  it 
has  been  found  that  the  cells  of  mahgnant  growths  do  not  conform  to 
this  rule,  because  one  daughter-cell  will  contain  more  than  it  should, 
while  its  fellow  contains  less  than  it  should.  It  is  probable,  therefore, 
that  this  disorder  in  growth  starts  from  the  very  beginning  of  cell  life. 


CANCER    OF    THE    STOMACH  631 

CANCER   OF  THE   ESOPHAGUS 

This  growth  necessarily  produces  stricture  and  difficulty  in 
swallowing,  first,  any  solid  food,  and  afterward,  equally  so,  any 
liquid  food.  Its  presence  may  be  readily  determined  by  passing  an 
esophageal  bougie.  I  was  once  consulted  by  a  physician  who  said  that 
he  passed  such  a  bougie  and  that  it  was  arrested  at  a  definite  point. 
As  the  patient  was  over  sixty  years  old,  he  made  a  diagnosis  of  cancer- 
ous stricture  of  the  esophagus.  On  examining  him  myself,  I  soon 
became  convinced  that  the  esophagus  was  pressed  upon  by  an  outside 
tumor,  and  further  examination  showed  that  he  had  numerous  tumors 
elsewhere,  both  in  the  neck  and  in  the  liver,  which  proved  to  be  the 
glandular  enlargements  of  Hodgkin's  disease.  When  due  to  cancer, 
it  is  in  the  form  of  an  epithelioma,  and  in  its  course  may  invade  the 
trachea  or  some  large  bronchus,  when  it  occasions  persistent  cough. 
If  situated  in  the  lower  part  of  the  esophagus,  this  tube  may  become 
dilated  above  the  stricture  so  as  to  retain  the  food  a  good  while  after 
it  is  swallowed,  until  it  is  brought  up  by  a  reverse  action  of  the  tube. 

CANCER  OF   THE  STOMACH 

Recent  statistics  seem  to  prove  that  cancer  of  the  stomach  is  only 
second  in  frequency  to  cancer  of  the  uterus.  It  is  more  common  in 
males  than  in  females.  As  to  age,  Welch  gives,  out  of  150  cases,  three- 
fourths  occurring  between  the  fortieth  and  the  seventieth  years.  The 
prevalent  conception  that  this  disease  is  hereditary  is  a  mistake;  it 
bears  no  comparison  with  tuberculosis  in  this  respect.  As  to  previous 
disorders  disposing  to  cancer,  the  statistics  of  the  Mayo  Clinic  are 
decisive.  They  state  that  nearly  75  per  cent,  of  gastric  cancers  orig- 
inate in  chronic  gastric  ulcers. 

Morbid  Anatomy. — The  most  common  varieties  of  gastric  cancer 
are  the  cyHndric-celled  adenocarcinoma,  the  encephaloid  or  medul- 
lary carcinoma,  the  scirrhus,  and,  lastly,  colloid  cancer.  As  to  situa- 
tion, the  pyloric  region  is  invaded  in  more  than  50  per  cent. ;  in  the  lesser 
curvature,  in  about  15  per  cent.;  at  thecardia,  in  10  per  cent.;  on  the 
posterior  wall,  in  8  per  cent.,  and  in  about  the  same  percentage  involv- 
ing the  whole  stomach,  while  only  about  5  per  cent,  occur  in  the  fundus. 

The  medullary  cancer  occurs  in  soft  masses  which  involve  all  the 
coats  of  the  stomach  and  usually  ulcerate  early,  with  effusion  of  blood. 
The  cylindric-celled  epithelioma  may  form  a  large  irregular  tumor, 
with  somewhat  firm  consistence.  The  scirrhus  variety  is  characterized 
by  great  hardness,  due  to  the  abundance  of  stroma.  It  is  found  most 
frequently  at  the  pylorus,  where  it  is  a  common  cause  of  stenosis,  and 


632  CLINICAL  MEDICINE 

may  be  secondary  to  cancer  of  the  ovaries.  Not  infrequently  there  is 
simultaneous  involvement  of  the  small  and  large  intestines.  The 
colloid  cancer  we  have  already  referred  to.  It  involves  all  the  coats 
of  the  stomach,  and  is  prone  to  spread  to  other  organs.  Cancer  of  the 
stomach  is  often  secondary  to  cancer  of  the  breast. 

Changes  in  the  Stomach. — Cancer  at  the  cardia  is  usually  associ- 
ated with  wasting  of  the  organ  and  reduction  of  its  size.  On  the  other 
hand,  annular  cancer,  at  the  pylorus,  causes  stenosis  with  great  dila- 
tation. In  diffuse  scirrhous  cancer  the  stomach  may  be  greatly  thick- 
ened and  contracted,  when  it  may  be  displaced  or  altered  in  shape  by 
the  weight  of  the  tumor,  particularly  in  cancer  of  the  pylorus,  when  it 
may  cause  difficulty  in  diagnosis,  for  its  mobility  is  such  that  it  may 
be  foimd  anywhere  in  the  abdomen,  even  down  in  the  true  pelvis.  It 
is,  however,  often  retained  in  a  particular  region  by  the  formation  of 
adhesions. 

As  might  be  inferred,  secondary  cancerous  growths  are  very  common. 
Besides  developing  in  various  organs,  notably  the  Hver,  the  lymphatic 
glands  are  frequently  affected.  When  the  cervical  and  inguinal  canals 
are  involved,  they  may  serve  to  give  a  clue  to  the  diagnosis,  and  Ukewise 
when  they  occur  under  the  skin,  particularly  about  the  navel. 

The  further  progress  of  this  fell  disease  may  cause  all  kinds  of 
complications,  such  as  perforation  into  the  peritoneum  or  into  differ- 
ent parts  of  the  intestines,  or  into  the  pleura,  the  lung,  or  even  into 
the  pericardium. 

Symptoms. — Sometimes  there  are  no  symptoms  pointing  to  the 
stomach,  and  the  tumor  is  found  unexpectedly  after  death.  In  other 
cases  the  s3rmptoms  are  not  gastric,  but  point  to  the  liver  or  some  other 
organ.  Occasionally,  in  elderly  persons,  there  is  gradual  asthenia, 
without  nausea  or  vomiting. 

In  many  cases  the  history  of  the  onset  was  sudden.  As  to  general 
symptoms,  progressive  emaciation  is  one  of  the  most  constant,  and  in 
some  cases  the  loss  of  weight,  without  assignable  cause,  constitutes 
the  most  ominous  symptom  of  the  case.  Usually  with  this  is  persist- 
ent loss  of  appetite,  and,  finally,  vomiting.  This  may  set  in  early,  and 
then  persist  with  such  violence  as  to  cause  a  fatal  termination  in  a 
few  weeks.  Vomiting  is  more  common  when  cancer  involves  the  py- 
lorus, though  it  may  then  be  delayed  for  more  than  an  hour  after  tak- 
ing food.  When  the  cardiac  orifice  is  involved,  it  may  follow  very 
soon  after  eating. 

We  have  already  mentioned  that  cancer  of  the  stomach  in  its  earh- 
est  stages  may  be  excised  with  permanent  cure  of  the  patient.     If  that 


CANCER    OF    THE    INTESTINAL    TRACT  633 

be  a  fact,  its  early  diagnosis  is  of  great  importance,  but  this  is  often  a 
matter  of  great  difficulty.  If  a  patient,  after  middle  life,  has  hitherto 
enjoyed  excellent  digestion,  the  advent  of  disordered  digestion  should 
always  be  regarded  with  suspicion. 

In  all  cases  of  suspected  gastric  cancer  a  careful  examination  of 
the  contents  of  the  stomach,  either  vomited  or  removed  by  the  stom- 
ach-tube, ought  to  be  carefully  made.  One  of  the  most  important 
indications  comes  from  absence  of  hydrochloric  acid.  This  may 
occur  in  other  chronic  diseases  of  the  stomach,  such  as  in  achyha  gas- 
trica  or  in  very  chronic  gastritis,  but  in  neither  of  these  conditions 
is  it  so  characteristic  as  in  gastric  cancer,  and  is  evidently  due  to  a 
specific  influence  of  the  disease.  At  one  time  I  thought  that  it  might 
occur  in  cancer  of  other  organs  than  the  stomach,  but  my  observa- 
tions are  not  numerous  enough  to  prove  this,  though,  so  far  as  they 
go,  they  render  it  highly  probable. 

Hematemesis,  or  vomiting  of  blood,  occurs  in  nearly  30  per  cent, 
of  all  cases  of  gastric  cancer.  Rarely  the  blood  is  bright  when  it  comes 
from  a  recently  formed  ulcer,  but  in  cancer  of  the  pylorus  the  vomited 
blood  is  usually  dark  colored,  and  when  mixed  with  other  ingredients 
is  often  called  "coffee-ground"  hematemesis.  It  is  not  so  profuse  as  it 
sometimes  is  in  gastric  ulcer,  but,  as  in  that  complaint,  it  may  occur 
as  the  first  symptom. 

Another  of  the  first  symptoms  of  cancer  is  a  tumor,  usually  first 
noted  about  the  epigastrium.  Being  in  the  stomach,  it  is  not  affected 
by  the  movements  of  respiration,  but  when  detected  the  valuable  sign 
in  all  abdominal  growths  is  to  find  what  part  of  it  has  no  free  border. 

Of  the  Durely  clinical  symptoms,  one  of  the  chief  is  the  existence  of 
pain.  Pain  is  a  very  important  symptom,  but  it  is  remarkable  how 
often  it  is  entirely  absent.  When  present  it  is  not  paroxysmal,  but 
may  be  referred  to  distant  parts,  such  as  the  shoulders  or  in  either  hypo- 
chondrium.  As  a  rule,  it  is  what  may  be  called  a  "wearing"  sensation, 
but  may  be  boring.  Its  chief  feature,  however,  is  its  persistence,  and 
may  or  may  not  be  aggravated  by  taking  food.  It  is  not  often  reHeved 
by  vomiting. 

CANCER  OF  THE  INTESTINAL  TRACT 

After  noting  the  characters  of  malignant  disease  of  the  stomach,  it 
becomes  evident  that  cancer  may  occur  in  any  part  of  the  body,  a  fact 
fully  illustrated  in  the  development  of  cancer  along  the  intestinal  canal. 
Thus,  it  may  occur  in  the  duodenum,  and  is  then  very  commonly  as- 
sociated with  persistent  jaundice.     It  is  of  comparatively  rare  devel- 


634  CLINICAL   MEDICINE 

opment  in  the  small  intestine  until  we  approach  the  region  of  the 
cecum,  where  it  is  relatively  common.  Cancers  of  the  intestine  are 
columnar  celled,  in  contrast  to  those  of  the  esophagus  and  skin,  which 
are  squamous  celled. 

When  cancer  develops  about  the  cecum  it  is  prone  to  form  metas- 
tases, particularly  in  the  liver  and  in  the  lung.  It  is  from  this  source 
also  that  the  commonest  metastases  in  the  brain  occur.  All  such 
mahgnant  growths  in  the  intestine  produce  their  characteristic  symp- 
toms according  to  which  part  is  involved,  because  in  most  cases  they 
produce  constriction  or  stenosis  of  the  tube.  If  the  location  is  not 
far  from  the  rectum,  deceptive  tumors  may  develop  from  simple  accu- 
mulation of  the  feces  above  the  stricture.  Cancer  of  the  rectum,  in 
fact,  is  one  of  the  common  sites  of  this  invasion,  and  should  be  detected 
early,  because  its  removal  by  surgical  operation  may  then  be  feasible. 
Its  earliest  symptom  is  usually  pain  in  the  act  of  defecation,  and  then, 
as  it  proceeds,  the  movements  have  a  pecuUarly  thin,  drawn-out  or 
ribbon-Hke  appearance.  An  early  examination  by  the  finger  should 
then  be  made,  when  the  tumor  may  be  readily  detected.  Higher  up 
the  symptoms  are  usually  those  of  coUcky  pains,  when  constitutional 
signs,  such  as  emaciation  and  cachexia,  may  indicate  how  serious  the 

trouble  is. 

CANCER  OF  THE  LIVER 

Primary  cancer  of  the  Hver  is  so  uncommon  that  it  should  lead  us 
to  search  for  a  focus  elsewhere  in  the  organ  or  in  the  neighboring  tis- 
sues for  that  to  which  the  liver  cancer  is  secondary.  Thus,  cancer  of 
the  gall-bladder  and  of  the  bihary  passages  is  a  common  result  of 
chronic  irritation  by  gall-stones.  It  is  also  not  uncommon  for  it  to 
be  secondary  to  cancerous  stricture  of  the  pylorus,  but,  whatever  the 
source,  the  soft  tissue  of  the  liver  seems  to  favor  great  development 
of  large  cancerous  tumors  in  the  substance  of  the  organ.  On  that 
account  cancer  of  the  liver  is  commonly  painless,  and  only  when  it  is 
developing  where  its  growth  may  implicate  the  bile-ducts  is  jaundice 
present,  except,  as  already  mentioned,  when  the  disease  begins  in  the 
duodenum.  I  have  known  the  hver  to  be  greatly  enlarged  on  account 
of  its  contained  cancerous  tumors,  without  either  pain  or  jaundice. 
On  the  other  hand,  a  coexistence  of  ascites  with  jaundice  is  very  sus- 
picious. When  the  liver  is  the  seat  of  cancerous  tumors  they  are 
usually  quite  palpable  on  examination,  often  discoverable  as  rounded 
projections  on  the  surface  of  the  Hver  or  along  its  edges.  Little  doubt 
also  of  their  being  hepatic  can  occur,  when  they  are  plainly  depressed 
by  the  descent  of  the  diaphragm  in  breathing.     The  prognosis  of  liver 


CANCER     OF    THE  LUNG  635 

cancer  is  invariably  bad,  emaciation  anr]  cachexia  attending  its  course 
early,  and  the  patients  rarely  surviving  the  first  year  of  the  complaint. 
Cancers  elsewhere  in  the  abdomen,  whether  in  the  pancreas  or  in 
the  adrenal  bodies,  are  pretty  sure  to  indicate  their  presence  by  the 
changes  in  the  functions  of  those  organs. 

CANCER  OF  THE  BREAST 

There  is  no  subject  which  causes  such  anxiety,  both  for  the  patient 
and  the  physician,  as  the  presence  or  not  of  cancerous  disease  in  the 
sexual  organs  of  women,  whether  of  the  uterus  or  of  the  breast.  With 
reference  to  the  uterus  suspicion  rarely  occurs  except  in  the  reappear- 
ance of  menstruation  after  it  has  normally  subsided  with  advancing 
years.  In  such  cases  the  reappearance  of  the  bloody  flow  after  men- 
struation has  ceased  for  several  years  does  not  mean  a  return  of  men- 
struation, but  is  always  due  to  some  organic  change  in  the  uterus 
itself,  very  often  the  advent  of  cancer  in  the  organ.  In  other  cases  sus- 
picion is  aroused  by  what  is  at  first  too  great  and  prolonged  a  flow  of 
blood  at  what  is  supposed  to  be  the  time  of  the  menopause.  Examina- 
tion then  should  be  made,  because  modern  surgery  has  shown  that  the 
whole  uterus  can  be  removed  and  little  danger  to  life  occasioned,  so 
that,  instead  of  succumbing  to  uterine  cancer,  the  patients  may  five 
for  years  in  good  health. 

The  first  signs  of  cancer  of  the  breast  should,  for  the  same  reasons, 
be  well  determined.  It  is  not  enough  for  such  purposes  to  find  a 
tumor  in  the  substance  of  the  breast,  for  such  growths  are  often  quite 
innocent. 

It  is  otherwise  if,  with  signs  of  hardening  within  the  gland,  the 
nipple  is  retracted  or  quite  distorted  when  compared  with  its  fellow 
in  the  other  breast.  If,  in  addition,  the  skin  is  not  easily  movable 
over  the  tumor,  and  dilated  veins  seem  to  radiate  from  the  nipple  out- 
ward, the  axilla  should  be  carefully  examined  to  note  whether  there 
are  any  enlarged  glands  in  it.  If  one  or  more  of  these  signs  are  pres- 
ent, no  time  should  be  lost  in  amputating  the  breast.  At  present  such 
operations  are  notably  successful,  because  surgeons  now  are  not  con- 
tent with  removing  only  the  breast,  but  make  sweeping  incisions  to 
insure  the  cutting  away  of  all  possibly  impKcated  lymphatic  glands  in 

the  axilla. 

CANCER   OF  THE  LUNG 

The  symptoms  of  cancerous  disease  of  the  lungs  differ  according 
to  whether  the  disease  is  primary  or  secondary.  If  secondary,  we 
have  every  reason  to  suspect  that  the  pulmonary  symptoms  simply 


636  CLINICAL  MEDICINE 

indicate  extension  from  a  known  cancerous  focus  elsewhere.  Then 
the  S5nnptoms  may  be  extremely  varied,  according  to  the  situation  of 
the  secondary  growths.  Primary  cancer  of  the  lung,  on  the  other 
hand,  may  for  a  long  time  be  obscure  in  its  signs.  It  occurs  more  fre- 
quently in  men  than  in  women,  and  a  common  first  s5rtnptom  is  rapid 
breathing  without  any  assignable  cause.  These  primary  tumors  are 
often  large,  and  then  the  symptoms  will  depend  upon  what  extra- 
pulmonary tissues  are  involved.  If  there  is  any  pressure  upon  the 
trachea  or  upon  a  large  bronchus,  cough  is  certain  to  develop.  If  the 
patient  survives  for  any  length  of  time,  the  veins  on  the  surface  of  the 
chest  may  be  very  prominent  and  dilated,  and  then  secondary  glandu- 
lar enlargements  occur,  more  commonly  visible  just  above  the  cla\icle. 
Primary  cancerous  deposits  may  first  develop  in  the  pleura,  and  give 
all  the  symptoms  of  generahzed  pleurisy,  with  or  without  any  effusion. 
In  them,  however,  it  is  peculiar  to  find  the  ribs  very  tender  on  pres- 
sure, which  is  explained  by  the  involvement  of  the  bones  in  the  can- 
cerous process.  One  pecuHarity  I  have  noticed  in  these  patients  is  a 
remarkable  diminution  in  the  percentage  of  urea  in  the  urine. 

No  civiUzed  country  in  the  world  is  at  present  without  institutions 
or  special  laboratories  for  cancer  research,  but  it  has  to  be  admitted 
that  we  seem  to  be  as  far  as  ever  from  knowing  what  cancer  or  sarcoma 
really  is.  Experimental  research  has,  therefore,  been  widely  attempted 
in  the  direction  of  transplanting  or  inoculating  animals  with  cancerous 
material.  It  was  soon  found,  however,  that  such  experiments  were 
always  unsuccessful  if  attempted  with  animals  of  different  species. 
Thus,  portions  of  cancerous  tumors  from  a  human  subject  can  never 
be  transplanted  to  any  other  animal.  On  the  other  hand,  it  has  been 
found  that  cancerous  growth  sometimes  occurs  spontaneously  in  mice, 
and  then  can  be  transferred  to  other  mice  and  grow  in  them.  Rats, 
because  they  are  allied  to  mice,  can  also  be  inoculated  from  mice, 
but,  as  we  have  already  stated,  this  experiment  is  only  partially  suc- 
cessful, for  it  does  not  kil  the  rat,  and  even  causes  that  animal  to 
become  immune  to  further  inoculation. 


SARCOMA 

Connective  tissue  is  necessarily  the  widest  spread  tissue  in  the 
body,  because  it  is  the  tissue  that  binds  together  all  the  specialized 
tissues  and  organs.  It  is,  therefore,  the  most  primitive  of  all  the  tis- 
sues ;  hence,  when  any  of  the  higher  tissues — such  as  muscular,  glandu- 
lar, or  nervous — degenerate  and  die,  the  connective  tissues  are  ever 


SARCOMA  637 

ready  to  take  their  places.  The  general  tendency  of  such  replacement 
is  to  shrink  in  bulk  and  to  harden  in  texture,  such  as  in  cirrhosis  of  the 
lungs  and  of  the  liver.  When  this  process  occurs  in  nervous  textures 
it  is  called  sclerosis. 

Now  it  is  from  these  primitive  and  least  dififerentiated  tissues  that 
all  sarcomata  are  derived.  Sarcomata  are  formed  of  Hving  cells,  and, 
therefore,  show  the  primal  property  of  indefinite  multiphcation. 
Where  the  element  of  simple  multiphcation  predominates  and  tissue 
differentiation  is  at  its  lowest,  the  resultant  growth  is  the  most  malig- 
nant in  its  character.  A  normal  cell  always  conforms  to  law  and  is 
checked  by  law,  but  a  malignant  cell  is  a  pure  anarchist,  whose  further 
growth  tends  only  to  ruin  and  premature  death.  Thus,  no  cancer 
shows  such  malignant  characteristics  as  a  melanotic  sarcoma,  which, 
beginning  in  the  choroid  membrane  of  the  eye,  rapidly  spreads  to  all 
parts  of  the  body. 

We  have  already  shown  that  malignant  tumors  are  deficient  in 
vitahty,  and,  therefore,  are  prone  to  ulcerate  and  to  break  down  where- 
ever  they  grow.  Sarcomata,  belonging  to  the  least  vital  and  least  dif- 
ferentiated of  tissues,  show,  therefore,  the  least  tendency  to  form  or- 
ganized growths.  This  is  well  illustrated  in  the  fact  that,  however 
vascular  they  seem  to  be  and,  therefore,  bleed  readily,  these  tumors 
do  not  possess  real  blood-vessels  Hke  many  cancers  do,  but  instead  form 
only  imperfectly  developed  blood-channels. 

Clinically,  sarcomata,  instead  of  developing  like  cancers  in  middle 
or  post-middle  Hfe,  are  often  foimd  among  the  young.  Thus  the 
hideous  and  rapidly  growing  sarcomata  of  the  eye  generally  occur  in 
children,  but,  as  we  have  remarked,  multiplication  of  cells  is  itself  a 
great  evidence  of  a  reversion  to  the  rapid  growth  of  cells  in  embryonal 
tissues,  and  if  such  multiplication  stops  short  of  true  organization  it 
then  assumes  the  worst  characters  of  malignant  growths.  There  is 
nothing,  therefore,  that  can  exceed  in  its  \mfavorable  import  the  man- 
ner in  which  a  multiplying  focus  of  sarcomatous  cells  invades  the  sur- 
rounding organized  tissues  and  destroys  them.  A  locahzed  cancerous 
tumor,  as  we  have  remarked,  may  develop  in  the  walls  of  the  stomach, 
and,  if  recognized  in  its  early  stages,  may  be  safely  excised,  but  it  is 
doubtful  if  there  be  a  parallel  instance  in  sarcoma.  We  can  never  be 
sure  that  its  cells  have  not  already  been  disseminated  far  and  wide  in 
the  system. 

The  most  frequent  seats  of  sarcoma  are  the  connective  tissue  of  the 
skin — periosteum,  intermuscular  septa,  tendons,  subserous  connective 
tissue,  and  the  eye. 


638  CLINICAL   MEDICINE 

Sarcomata  assume  a  great  variety  of  forms,  according  to  the  situa- 
tion of  the  connective  tissue  in  which  they  originate,  and  hence  are 
named  accordingly,  but  owing  to  their  numerous  varieties  we  need  not 
enumerate  them  by  name.  One  of  the  most  singular  of  these  forms  is 
what  is  called  a  psammoma,  which  develops  in  the  substance  of  the 
brain.  I  had  a  patient  in  whom,  after  some  months  of  illness,  there 
was  found  at  autopsy  thousands  of  such  collections  scattered  all 
through  the  white  matter  of  his  brain,  so  that  no  incision  anywhere 
could  be  made  without  encountering  gritty  particles,  which  proved,  on 
examination,  to  be  composed  of  carbonate  of  lime. 


TREATMENT  OF  CARaNOMA  AND  SARCOMA 

As  to  treatment,  we  have  already  mentioned  that  previous  to  the 
introduction  of  radium  the  only  measure  was  by  surgical  excision  of 
the  growths.  The  remedial  effects  of  radium,  however,  require  a 
fuller  statement  of  its  details,  for  this  mysterious  element,  radium,  has 
already  caused  a  revolution  in  the  conceptions  of  physicists  about  the 
constitution  of  matter  itself,  suggesting  that  in  this  substance  we  have 
the  spectacle  of  a  material  atom  undergoing  disintegration,  and  while 
doing  so  setting  free  a  variety  of  powerful  forces  which  could  be  re- 
vealed to  us  in  no  other  way.  Thus,  it  emits  a  number  of  lines  of  force 
called,  respectively,  alpha-,  beta-,  and  gamma-rays.  Dr.  Abbe  states, 
in  his  reprint  on  "The  Use  of  Radium  in  MaHgnant  Diseases,"  "After 
suitable  exposure  of  seeds  to  varying  amounts  of  soft  and  hard  rays, 
issuing  in  incessant  streams  from  this  wonderworking  mineral,  we 
watch  them  grow  and  see  three  results:  (i)  A  death-dealing  force  has 
played  upon  the  nearby  seeds  so  that  their  life  is  destroyed;  (2)  upon 
seeds  a  little  further  removed  a  stimulating  effect  has  occurred,  won- 
derful to  relate,  so  that  their  growth  is  greater  than  that  of  seeds  which 
have  had  no  radium;  and  (3)  at  distances  beyond  that  of  stimulation, 
where  the  hard  gamma-rays  have  played  relentlessly  upon  the  seed  life, 
they  show  a  retarded  vitality,  and  are  depressed  in  their  growth  more 
and  more  up  to  a  point  several  inches  away  from  the  radium.  The 
range  of  action  of  alpha-rays,  we  are  told,  is  within  J  inch,  that  of 
beta-rays  somewhere  about  li  inches,  but  the  gamma-rays  are  ultra- 
penetrating. 

"Judged  from  complete  demonstrations  which  can  be  illustrated  on 
a  photograph,  we  have  a  proof  that  we  can  produce  three  different 
effects  upon  the  cells  by  the  correct  use  of  radium:  (i)  Destruction  of 
life;  (2)  stimulation;  and  (3)  depression  and  retrograde  change.     I  shall 


TREATMENT    OF    CARCINOMA    AND    SARCOMA  639 

endeavor  to  show  that  the  surgeon  can  utilize  the  third  so  that  he  can 
at  will  produce  that  retrograde  change  in  cells  which  have  shown  erratic 
overgrowth  and  formed  life-destroying  tumors.  Partial  success,  or 
discouraging  failures  of  the  past,  may  be  largely  due  to  ignorance  of  the 
baneful  influence  of  the  alpha-  and  beta-rays  which  one  can  now  elim- 
inate. In  this,  I  think,  we  put  our  linger  on  the  weak  spot  in  radium 
treatment.  If  the  beta-rays  stimulate,  we  certainly  do  not  want  them; 
it  is  fair  to  say  that  gamma  radiation  is  oar  aim." 

I  have  seen  remarkable  changes  for  the  better  in  a  large  ulcerating 
cutaneous  cancer  by  the  use  of  radium.  This  occurred  in  a  patient  of 
mine,  a  lady  of  about  seventy  years  of  age,  after  the  apphcation  of 
radium  by  Dr.  Robert  Abbe.  The  epitheUoma  had  caused  a  very 
chronic  ulceration  of  the  skin  for  six  years,  until  it  was  as  extensive  as 
the  palm  of  a  hand,  with  fun  gating  edges,  particularly  the  upper  end. 
Dr.  Abbe  used  the  radium  at  intervals  of  seven  days.  The  result 
seemed  to  be  an  advance  of  quite  healthy  skin  at  all  the  edges  of  the 
ulcer.  After  two  months'  use  of  radium  the  ulcer  was  diminished 
quite  one-half  in  extent.  To  me  the  most  striking  feature  about  the 
case  was  the  perfectly  healthy  and  normal  appearance  of  the  new  skin, 
which  at  all  times  could  be  plainly  distinguished  from  the  diseased 
tissue.  I  was,  therefore,  very  sorry  that  in  time  the  patient  ceased 
from  pursuing  the  treatment. 

Very  recently  Dr.  Abbe,  in  connection  with  Dr.  Howard  A.  Kelly, 
of  Baltimore,  has  published  what  appeared  to  be  extraordinary  cures 
of  a  great  variety  of  surface  cancerous  tumors  by  the  use  of  radium. 
One  remarkable  case,  reported  by  Dr.  Howard  A.  KeUy,  was  that  of  the 
cure  of  a  cancer  of  the  larjnix  by  the  penetration  of  the  radium  rays 
through  the  skin  of  the  neck. 

How  radium  acts  upon  malignant  tumors  is  difficult  to  explain, 
except  that,  as  we  have  already  mentioned,  malignant  growths,  though 
composed  of  living  cells,  are  very  deficient  in  vitality  as  compared  with 
normal  cells,  and  the  gamma-ray  of  radium  appears  capable  of  destroy- 
ing the  malignant  cells  without  affecting  the  normal  cells.  In  rare 
cases  cancerous  tumors  have  been  known  to  get  well  spontaneously, 
owing  to  the  supervention  of  fatty  degeneration. 

In  all  his  cases  Dr.  Abbe  has  taken  photographs  of  the  lesions  at 
four  periods  in  the  treatment  of  cancer  of  the  eyelids,  nose,  and  chin, 
with  one  case  of  osteosarcoma  of  the  head  of  the  humerus,  which, 
after  apparently  complete  destruction  of  the  bone,  was  finally  cured, 
with  restoration  of  the  joint  to  its  normal  size.  I  have  never 
seen  such  remarkable  results  in  the  treatment  of  superficial  cancers, 


540  CLINICAL  MEDICINE 

which  time  and  again  showed  not  only  restoration  of  extensively 
ulcerated  parts,  but  with  no  scars  remaining.  In  one  case,  where  the 
upper  eyeHd  appeared  eaten  away,  the  restoration  after  the  use  of 
radium  was  so  complete  that  no  one  could  tell  which  was  the  Ud 
involved. 


INDEX 


Abdominal  cavity,  pulsation  in,  251 
organs,  displacement,  369 
viscus,  accidents  to,  vomiting  in,  62 
Abductor  paralysis,  bilateral,  599 

imilateral,  599 
Abscess  of  brain,  621 
of  liver,  412 

in  amebic  dysentery,  389 
of  lung,  331 
of  pancreas,  418 
perinephric,  441 
treatment,  442 
Acarus,  504 

Achlorhydria  haemorrhagica  gastrica,  360 
Achylia  gastrica,  360 

treatment,  360 
Aconite  in  angina  pectoris,  294 
in  aortic  stenosis,  284 
in  arteriosclerosis,  265 
in  chronic  interstitial  nephritis,  430 
in  inflammatory  pain,  32 
in  mitral  regurgitation,  290 
Aconitin  in  trigeminal  neuralgia,  592 
Acoustic  nerve,  595 
Acromegaly,  466 
treatment,  467 
Actinomycosis,  206 

treatment,  206 
Acute  yellow  atrophy  of  liver,  413    . 
Addison's  disease,  467 
symptoms,  468 
treatment,  469 
Adductor  paralysis,  599 
Adiposis  dolorosa,  462 
Adrenal  extract  in  Addison's  disease,  469 
glands,  467 
cancer  of,  635 
internal  secretion  of,  250 
Adrenalin,  468 
in  epistaxis,  246 
properties  of,  468 
Agglutinins,  71 

Ague,  209.     See  also  Malaria. 
41 


I  Ague-cake,  415 
Air,  fresh,  in  tuberculosis,  171 
Air-hunger  in  diabetes,  455 
Albuminuric  retinitis,  587 
Alcohol,  action  of,  on  brain,  511 

in  typhoid  fever,  160 
Alcoholic  cirrhosis  of  liver,  406 
symptoms,  408 
treatment,  409 
drinks,  use  of,  342 
neuritis,  583 
Alcoholism,  342,  508 
Alimentarj^  glycosuria,  456 
Alkaline  treatment  of  rheumatic  fever,  191 
Alopecia  in  syphilis,  118 
Alteratives,  70 
Amaiurosis,  uremic,  433 
Amboceptor,  71 
Amebic  dysenter\',  388 
abscess  of  liver  in,  389 
treatment,  390 
.Amenorrhea,  heat  in,  66 
Ampulla  of  Vater,  416 
Amyl  nitrite  in  angina  pectoris,  293 
Amyloid  degeneration  of  kidney,  414 
of  liver,  414 
treatment,  414 
Amyotrophic  lateral  sclerosis,  559 
symptoms,  559 
treatment,  560 
Anaplasia,  627 
Anarcotin  in  malaria,  218 
Anemia,  febrile,  250 
neuralgic  pains  in,  39 
pernicious,  241 
arsenic  in,  243 
clinical  course,  241 
etiology,  242 
treatment,  243 
primary,  240 
secondary,  240 
Anesthesia,  hysteric,  540 
Anesthetic  leprosy,  185 

641 


642 


INDEX 


Aneurysm,  267 
aortic,  267 

auscultation  in,  270 
dyspnea  in,  271 
hemorrhage  in,  271 
inspection  in,  269 
Oliver's  sign  in,  270 
pain  in,  271 
palpation  in,  270 
percussion  in,  270 
symptoms,  268 
arteriovenous,  268 
dissecting,  267 
false,  268 
micro  tic,  268 
miliary,  267 

of  aorta,  267.     See  also  Aneurysm,  aortic. 
popliteal,  271 
saccular,  267 
symptoms,  268 
thoracic,  cough  in,  53 
Aneurysmal  varix,  268 
Angina  pectoris,  39,  291 
false,  294 
neurotic,  294 
symptoms,  293 
treatment,  293 
ulcerosa  in  scarlet  fever,  88 
Angioneurotic  edema,  584 

treatment,  585 
Angiospasm,  428 

in  arteriosclerosis,  264 
Anguillula  stercoralis,  504 
Animal  parasites,  diseases  caused  by,  494 
Ankylostoma  duodenale,  500 
Ankylostomiasis,  500 

treatment,  502 
Anorexia,  47 

nervosa,  48 
Anthrax,  166 

treatment  167 
Antibody,  71 

Antitoxin,  diphtheria,  loi 
dose  of,  loi 
tetanus,  223 
Aorta,  aneurysm  of,  267.      See  also  Aneu- 
rysm, aortic. 
double,  267 
Aortic  aneurysm,  267.     See  also  Aneurysm, 
aortic. 
regurgitation,  285 
murmur  in,  286 
treatment,  286 


Aortic  stenosis,  284 
treatment,  284 
Aphasia,  613 

telephone,  616 
Aphthous  stomatitis,  334 
Apoplexy,  602 

conjugate  deviation  in,  609 
serous,  613 
treatment,  606 
Appendicitis,  377 
pain  in,  28,  377 
pulse  in,  378 
treatment,  378 
Arachnids,  parasitic,  504 
Argyll-Robertson  sign  in  tabes  dorsalis,  126 
Arsenic  in  diabetes,  458 
in  malaria,  215 
in  pernicious  anemia,  243 
Arsenic-poisoning,  519 
Arterial  atheroma,  261,  263 
pulsation,  251 

in  abdominal  cavity,  251 
in  Graves'  disease,  253 
structure,  261 
Arteries,  cerebral,  diseases  of,  602 
changes  in,  in  sjT)hilis,  119 
examination  of,  249 
in  typhoid  fever,  151 
Arteriorenal  sclerosis,  431 

treatment,  432 
Arteriosclerosis,  260 
angiospasm  in,  264 
etiology,  263 
treatment,  265 
Arteriovenous  aneurysm,  268 
Artery,  coats  of,  261,  262 
inner  coat,  261 
middle  coat,  262 
outer  coat,  262 
radial,  palpation  of,  249 
Arthritis  deformans,  299 
etiology,  299 
treatment,  301 
gonorrheal,  136 
gouty,  448 

rheumatic  arthritis  and,  differentiation, 
27,  189,  190 
in  scarlet  fever,  91 
rheumatic,  186,  299 
etiology,  299 
gouty  arthritis  and,  differentiation,  27, 

189,  190 
treatment,  301 


INDEX 


643 


Arthropathies,  298 
Artistic  poison,  509 
Ascarides,  499 

treatment,  500 
Ascaris  lumbricoides,  499 
Ascites,  366 

treatment,  367 
Asiatic  cholera,   161.        See  also  Cholera, 

Asiatic. 
Aspiration  in  pleurisy,  326 
Association  iibers,  615 
Asthma,  306 

bronchitic,  306 
treatment,  310 

etiology,  307 

hay-,  310 

peptic,  308 

treatment,  309 
Astringents,  69 
Ataxia,  locomotor,   124.        See  also   Tabes 

dorsalis. 
Atheroma,  arterial,  261,  263 
Atoxyl  in  pellagra,  205 
Atrophic  paralysis,  chronic,  566 
Atrophy,  acute  yellow,  of  liver,  413 

muscular,  44 
progressive,  566 

of  mucous  membrane  of  stomach,  360 

optic,  588 

in  tabes  dorsahs,  128 

progressive  muscular,  566 
Auditory  canal,  594 

nerve,  affections,  594 
Auriculoventricular  bundle  of  His,  259 
Auscultation,  cardiac,  272 

in  aortic  aneurysm,  270 

in  lobar  pneimionia,  142 
Autodigestion  of  pancreas,  416 

of  stomach,  347 
Autogenous  vaccine,  72 
Autositic  malignant  growths,  628 
Axon,  521 
Azoturia,  454 

Babinski's  reflex,  607 
Bacillary  dysentery,  386 
symptoms,  387 
treatment,  387 
Bacillus,  74 

coli,  infections  by,  232 

treatment,  235 
comma,  163 
dysenterica,  386 


Bacillus,  Eberth's,  147 

enteritidis,  161 

Friedliinder's,   139 

Gartner's,  161 

influenza,  112 

Klebs-Lofiler,  100 

lepra,  184 

of  anthrax,  166 

pestis,  80 

tetanus,  222 

tubercle,  168 
role  of,  170 

tj^hosus,  147 
in  gall-bladder,  396 
Bacteremia,  vaccine  in,  72 
Bacteria,  73 

entrance  into  bodj',  75 

filterable,  75 

in  feces,  372 

in  gall-bladder,  396 

in  intestinal  tract,  372 

in  urine,  445 

invasion  of,  after  catching  cold,  20 

method  of  leaving  body,  76,  79 

ultramicroscopic,  75 

virulence  of,  76 
Bacterial  infection  as  cause  of  emaciation,  43 
Bacterinuria,  445 
Bacterium,  74 
Bad  breath,  336 

treatment,  336 
Balantidium  coli,  502 

treatment,  502 
Banti's  disease,  415 
Bath,  Brand,  in  typhoid  fever,  158 

cold,  in  typhoid  fever,  158 
Bed-sores,  43 

in  myelitis,  582 

prevention  of,  43,  44 
Belladonna  and  arsenic  in  hay-fever,  310 

in  whooping-cough,  108 
Bell's  paralysis,  593 
Bennett  on  treatment  of  putrid  or  stercora- 

ceous  vomiting,  62 
Beriberi,  clinical  course,  203 

treatment,  204 
Bile,  395,  396 
Bile-ducts,  stenosis  of,  401 
Biliary  colic,  397-400 

treatment,  34 
Bilious  remittent  fever,  213 
Binder,  Rose's,  in  enteroptosis,  371 
Black  death,  82 


644 


INDEX 


Black  measles,  94 
small-pox,  85 

urine,  445 

vomit  in  yellow  fever,  221 
Bladder,  calculi  in,  436 

inflammation  of,  437 

irritability  of,  in  Graves'  disease,  483 

phosphatic  calculi  in,  436 

washing  of,  in  chronic  cystitis,  438 
Bleeding,  245 
Blepharospasm,  594 
Blindness,  color-,  587 

word-,  614,  615,  617 
Block,  heart-,  259 
Blood  conditions  as  cause  of  dyspnea,  58 

diseases  of,  237 
Bloodletting,  19 
Blood-pressure,  64 
Blood-vessels,  diseases  of,  249 
Blue  line  in  lead-poisoning,  517 
Bones,  affections  of,  in  tabes  dorsalis,  1 29 

diseases  of,  297 

tuberculosis  of,  183 
Bothriocephalus,  494 
Bovine  heart,  285 

tuberculosis,  169 
Brachial  neuralgia,  pain  of,  35 

neviritis,  572 

plexus,  affections  of,  572 
Bradycardia,  281 
Brain,  abscess  of,  621 

action  of  alcohol  on,  511 
of  drugs  on,  507-514 

diseases  of,  613 

edema  of,  613 

glioma  of,  620 

inflammation  of,  619 

psammoma  of,  621 

syphilitic  tumors,  621 

syphiloma  of,  620 

tabes  of,  133 

tumors  of,  620 
Brand  bath  in  typhoid  fever,  158 
Brauer's  operation  of  cardiolysis  in  peri-peri- 
carditis, 281 
Breast,  cancer  of,  635 

pigeon,  461 
Breath,  bad,  336 

treatment,  336 
Breathing,  difficult,  56.     See  also  Dyspnea. 
Brick-dust  deposit  in  urine,  437 
Bright's  disease.     See  Nephritis. 
Broca's  convolution,  614 


Bromids  in  epilepsy,  531 
Bromin  in  diphtheria,  106 
Bronchiectasis,  320 
Bronchitic  asthma,  306 

treatment,  310 
Bronchitis,  21,  314 

acute,  314 

symptoms,  315 
treatment,  315  "^ 

capillary,  318 

chronic,  317 
treatment,  317 

complications  of,  mechanism,  21 

dyspnea  in,  57 

emaciation  in,  45,  46 

fibrinous,  317 
treatment,  318 

gouty,  449 

in  diabetes  mellitus,  455 

in  pertussis,  108 

in  typhoid  fever,  151,  157 
Bronchophony  in  phthisis,  178 
Bronchopneumonia,  21,  318 

in  measles,  94 

in  pertussis,  108 

in  scarlet  fever,  91 

symptoms,  319 

treatment,  319 
Brown- tail  moth,  506 
Buboes  in  plague,  treatment,  83 

suppurating,  125 
Bubonic  plague,  82 
Buchu  in  pyelitis,  439 
Bulbar  paralysis,  568 
Bulimia,  545 

in  Graves'  disease,  482 
Burning  heat  of  skin  in  lobar  pneumonia,  140 

pain,  30 
Button,  mescal,  habit  from  chewing,  509 

Cachexia,  cancerous,  627 
Calcium  lactate  in  hemophilia,  246 
in  purpura,  247 
in  rickets,  461 
in  tetany,  465 
Calculus,  hepatic,  pain  in,  28 
pancreatic,  419 
phosphatic,  in  bladder,  436 
renal,  435 

pain  in,  28 
vesical,  436 
Camphor  as  stimulant  for  heart  failure  in 
lobar  pneumonia,  145,  146 


INDEX 


64s 


Cancer,  627,  628 

as  cause  of  emaciation,  46 

of  adrenal  bodies,  635 

of  breast,  635 

of  esophagus,  631 

of  intestinal  tract,  633 

of  liver,  634 

of  lung,  635 

of  pancreas,  635 

of  rectum,  634 

of  stomach,  631 

as  cause  of  emaciation,  46,  47 
changes  in  stomach,  632 
coffee-ground  hematemesis  in,  633 
hematemesis  in,  633 
morbid  anatomy,  631 
pain  in,  633 
symptoms,  632 
vomiting  in,  62 
radium  in,  638 
treatment,  638 
Cancerous  cachexia,  627 
Cancroid,  125 
Cannabis  indica  habit,  508 
Capillaries,  diseases  of,  257 
Capillary  bronchitis,  318 
Capsulitis,  chronic,  392 
Caput  medusa,  407 
Carbohydrates  in  diabetes,  452 
Carbuncles  after  small-pox,  86 
Carcinoma.     See  Cancer. 
Cardiac  branches  of  pneumogastric  nerve, 
derangements,  599 
crises  in  tabes  dorsalis,  129 
dyspnea,  57 
Carriers,  dysentery,  386 
scarlet  fever,  89 
typhoid,  76,  149 
Caseous  change  from  tuberculosis,  170 
Castor  oil  in  mucous  colitis,  384 
Catalepsy,  533 
Catarrh,  intestinal,  362 
nasal,  from  catching  cold,  20 

treatment,  22 
of  respiratory  tract  from  catching  cold,  20 
Catarrhal  jaundice,  394 
Catching  cold,  17 

acute  nephritis  from,  422 

catarrh  of  respiratory  tract  from,  20 

etiology  of,  17 

invasion  of  bacteria  after,  20 

nasal  catarrh  from,  20 

relation  of  vasomotor  nerves  to,  18 


Caterpillars,  affections  from,  506 
Cells,  hair-,  596 
Cerebral  arteries,  diseases,  602 
symptoms  of  uremia,  433 
syphilis,  120 
tumors,  620 
Cerebrospinal  meningitis,  195 
clinical  symptoms,  195 
Kernig's  sign  in,  197 
treatment,  197 
Cervico-occipital  neuralgia,  35 
Cervix  uteri,  irritation  of,  as  cause  of  cough, 

54 
Cestodes,  494 
Chancre,  Hunterian,  116 

soft,  125 
Change  as  remedy,  67 
Charcot's  disease  in  tabes  dorsalis,  129 
Chest,  examination  of,  in  phthisis,  177 

protectors,  23 
Chilblains,  554 
Chill,  pathology  of,  affecting  localized  areas 

of  skin,  17 
Chloroform  in  tetanus,  225 
Chlorosis,  237 
treatment,  238 
venous  thrombi  in,  238 
Choked  disk,  588 
Cholecj'-stitis,  395 
Cholelithiasis,  395 
colic  in,  397-400 
Courvoisier's  law  in,  400 
diagnosis,  397 
etiology,  395 

indication  for  surgical  operation,  403 
pain  in,  397-400 

surgical  operation,  indications  for,  403 
symptoms,  397 
treatment,  402 

surgical  indications  for,  403 
Cholera,  Asiatic,  161 

rice-water  discharges  in,  163 
symptoms,  164 
treatment,  165 
infantimi,  374 

treatment,  376 
morbus,  374 

treatment,  376 
nostras,  374 
sicca,  164 
Choleraic  diarrhea,  374 

treatment,  376 
Cholesterin,  396 


646 


INDEX 


Chordee,  135 
Chorea,  192 

clinical  course,  192 
diplococcus  rheumaticus  in,  187 
treatment,  194 
Choroiditis  from  Bacillus  coli,  233 
Chyluria,  443 
Circle  of  Willis,  603 

Circulation,  compensatory,  of  liver,  407 
Circulatory  apparatus,  diseases  of,  249 
symptoms  of  uremia,  434 
system  in  tabes  dorsalis,  129 
Circumflex  paralysis,  573 
Cirrhosis,  Hanot's,  411 
of  liver,  406 
alcoholic,  406 
symptoms,  408 
treatment,  409 
as  cause  of  emaciation,  50 
fatty,  409 
hypertrophic,  411 
treatment,  411 
in  children,  410 
syphilitic,  409 
of  lung,  328 
treatment,  329 
Clapotage,  370 
Clavus  hystericus,  541 
Clergyman's  sore  throat,  313 
Cocain  habit,  509 
Cocci,  74 
Cochlea,  595 
Codein  in  diabetes,  457 
Cod-liver  oil  in  diabetes,  458 
in  phthisis,  175 
in  rickets,  461 
Coffee-ground    hematemesis    in    cancer    of 

stomach,  633 
Cohnheim's  theory  of  origin  and  nature  of 

malignant  growths,  629 
Colchicum  in  gout,  450 
Cold,  action  of,  65 
as  hemostatic,  65 
as  tonic,  65,  66 
bath  in  typhoid  fever,  158 
catching,  17 

acute  nephritis  from,  422 
catarrh  of  respiratory  tract  from,  20 
etiology  of,  17 

invasion  of  bacteria  after,  20 
nasal  catarrh  from,  20 
relation  of  vasomotor  nerves  to,  18 
ro;e,  311 


Cold,  susceptibility  of  vasomotor  nerves  to, 

20 
Colic,  34 
biliary,  treatment,    34 
gall-stone,  397-400 

gastralgia  and,  differentiation,  399 
hepatic,  34 
lead-,  517 
renal,  34 

treatment,  34 
Colitis,  mucous,  379 
symptoms,  382 
treatment,  383 
Colles'  law,  120 
Colloid  degeneration  in  malignant  tumors, 

629 
Colon  bacillus,  infections  by,  232 

treatment,  235 
Color-blindness,  587 
Comma  bacillus,  163 
Compensatory  circulation  of  liver,  407 
Complement,  71 

Compound  phenacetin  pill  in  influenza,  113 
Condylomata,  118 

Conjugate  deviation  in  apoplexy  and  hemi- 
plegia, 609 
Conjunctivitis,  diphtheric,  102 
Constipation,  368 
in  Graves'  disease,  482 
in  typhoid  fever,  150,  154 
treatment,  368 
Constitutional  medicine,  68 
Contagious  diseases,  75 
Contractures,  hysteric,  540 
Convolution,  Broca's,  614 
Convulsions,  epileptiform,  in  uremia,  433 
in  epilepsy,  525 
infantile,  533 
treatment,  534 
Corrigan  pulse,  285 
Corrosive  sublimate  in  arteriosclerosis,  266 

in  chronic  interstitial  nephritis,  430 
Corynebacterium  Hodgkini,  296 
Coryza,  304 

treatment,  304 
Cough,  51 
dry,  72 
expectorant,  51,  54 

treatment,  55 
hysteric,  54 
in  acute  pleurisy,  52 
in  hepatitis,  53 
in  lobar  pneumonia,  140 


INDEX 


647 


Cough  in  pertussis,  53 
in  phthisis,  177 
in  pleurisy,  323 
in  thoracic  aneurysm,  53 
in  valvular  disease  of  heart,  53 
intestinal  worms  as  cause,  54 
irritant,  51 

varieties  of,  51,  52 
irritation  of  cervix  uteri  as  cause,  54 

of    external    meatus   of   ear  as  cause, 

53 
tight,  55 
undigested  contents  in  stomach  as  cause, 

54 
Counterirritation,  19 
Courvoisier's  law  in  gall-stones,  400 
Cramps,  33 

Cranial  nerves,  diseases,  586 
Creosote  carbonate  in  lobar  pneumonia,  145, 
146 
in  phthisis,  175 
Cretinism,  469 

treatment,  471 
Crisis,  75 

cardiac,  in  tabes  dorsahs,  129 

Dietl's,  446 

gastric,  in  tabes  dorsalis,  1 28 

in  croupous  pneumonia,  142 

intestinal,  in  tabes  dorsalis,  129 

laryngeal,  in  tabes  dorsalis,  129 

vesical,  in  tabes  dorsalis,  128 

visceral,  in  tabes  dorsalis,  128 
Croup,  spasmodic,  314 
Crus,  hemorrhage  in,  in  hemiplegia,  609 
Cupping,  dry,  in  acute  nephritis,  423 
Cutaneous  nerve,  external,  injury  of,  paral- 
ysis af'^er,  576 

reflex  pains,  27,  41 
Cyanosis,  248 
Cystinuria,  444 
Cystitis,  437 

treatment,  438 
Cysts,    echinococcus,    496.     See    also    Hy- 
datid cysts. 

hydatid,  496.     See  also  Hydatid  cysts. 

of  kidney,  445 

of  pancreas,  419 


Dead  fingers,  248 

Deafness,  596 
in  tabes  dorsalis, 
word-,  596,  614 

Death,  black,  82 


128 


Degeneration,  amyloid,  of  kidney,  414 
of  liver,  414 
treatment,  414 
colloid,  629 

in  malignant  tumors,  629 
hyaline,  in  malignant  tumors,  629 
spinal,  in  tabes  dorsalis,  130 
Delirium,  613 
in  lobar  pneumonia,  143 
in  typhoid  fever,  150,  156 
tremens,  342 
Dendrites,  520 
Dengue,  202 
Derbyshire  neck,  463 
Dercum's  disease,  462 
Dermacentor  occidentalis,  505 
Desquamation  in  scarlet  fever,  89 
Deviation,  conjugate,  in  apoplexy  and  hemi- 
plegia, 609 
Diabetes  insipidus,  459 
mellitus,  451 

air-hunger  in,  455 
as  cause  of  emaciation,  50 
bronchitis  in,  455 
carbohydrates  in,  452 
complications,  455 
lipemia  in,  455 
proteins  in,  454 
symptoms,  455 
treatment,  456 
urea  in,  454 
Diarrhea,  361 

as  cause  of  emaciation,  49 
choleraic,  374 

treatment,  376 
in  children,  373 
in  Graves'  disease,  481 
in  measles,  95 

in  typhoid  fever,  149,  154,  363 
symptoms,  363 
treatment,  363 
Diet,  egg-albumen,  in  gastric  ulcer,  352 
in  cholelithiasis,  403 
in  Graves'  disease,  488-491 
in  hyperchlorhydria,  358 
in  migraine,  553 
in  mucous  colitis,  385 
in  tuberculosis,  172 
in  typhoid  fever,  160 
Dietl's  crisis,  446 
Digestion,  habits  and,  338 
mental  interest  and,  339 
organs  of,  disorders,  333 


648 


INDEX 


Digestive  disturbances  in  Graves'  disease, 

479 
Digitalis  in  mitral  regurgitation,  290 
Dilatation,  gastric,  acute,  355 
treatment,  355 
chronic,  355 
treatment,  356 
Diphtheria,  99 
antitoxin,  loi 

dose,  loi 
diagnosis,  105 
emaciation  in,  45 
kidney  affections  in,  104,  106 
laryngeal,  104 
nephritis  in,  104 
treatment,  107 
of  eye,  102 
treatment,  105 
virulence  of,  103 
Diphtheric  affections  of  heart,  treatment, 
106 
conjimctivitis,  102 
paralysis,  103 
treatment,  106 
Diplococcus,  74 
rheumaticus,  186 
in  chorea,  187 
Displacement  of  abdominal  organs,  369 

of  kidney,  446 
Dissecting  aneurysm,  267 
Disseminated    sclerosis,    556.  See    also 

Sclerosis,  disseminated. 
Double  aorta,  267 

Douching  throat  as  preventive  of  rheumatic 
fever,  192 
in  scarlet  fever,  91 
Dracontiasis,  502 
treatment,  502 
Dreams,  mechanism  of,  615 
Dropsy,  58.    See  also  Edema. 
Drug  habits,  507 
Drugs,  action  of,  on  brain,  507-514 

cyanosis  from,  248 
Dry  cough,  52 
Ductless  glands,  463 
diseases,  463 

relation  of,  to  metabolism  of  carbohy- 
drates, 453 
Duodenal  ulcer,  347 
himger  pain  in,  351 
symptoms,  351 
Dysentery,  361,  386 
amebic,  388 


Dysentery,  amebic,  abscess  of  liver  in,  389 
treatment  of,  390 

as  cause  of  emaciation,  49 

bacillary,  386 
symptoms,  387 
treatment,  387 

carriers,  386 
Dyspepsia,  370,  546 
Dyspnea,  56 

blood  conditions  as  cause,  58 

cardiac,  57 

hemic,  58 

in  aortic  aneurysm,  271 

in  bronchitis,  57 

in  lobar  pnemnonia,  140 

in  pericarditis,  57 

pulmonary,  56 

significance  of,  56 

valvular  disease  of  heart  as  cause,  58 

Ear,  anatomy  of,  594 

examination  of,  597 

external,  594 

inner,  595 

middle,  595 

ringing  in,  597 
Eberth's  bacillus,  147 
Echinococcus  cysts,  496.     See  also  Hydatid 

cysts. 
Edema,  58 

angioneurotic,  584 
treatment,  585 

in  Bright's  disease,  60 

of  brain,  613 

of  glottis,  313 

renal,  60 

significance  of,  58 
Effusion  in  pleurisy,  324 
Egg-albumen  diet  in  gastric  ulcer,  352 
Egophony  in  pleurisy,  323 
Eighth  nerve,  595 
Electricity,  64 

uses  of,  64 
Elephantiasis  of  legs,  444 
Eliminatives,  69 
Emaciation,  42 

bacterial  infection  as  cause  of,  43 

carcinoma  as  cause,  46 
of  stomach  as  cause,  46,  47 

causes  of,  43 

cirrhosis  of  liver  as  cause,  50 

diabetes  mellitus  as  cause,  50 

diarrhea  as  cause,  49 


INDEX 


649 


Emaciation,  diseases  of  intestines  as  cause, 

47 
of  stomach  as  cause,  47 

dysentery  as  cause,  49 

etiology,  43 

gastritis  as  cause,  47 

gastro-intestinal  disorders  as  cause,  47 

Graves'  disease  as  cause,  50 

in  bronchitis,  45,  46 

in  diphtheria,  45 

in  Graves'  disease,  482 

in  phthisis,  45,  46,  177 

in  pneumonia,  45 

in  typhoid  fever,  45 

mahgnant  diseases  as  cause,  46 

neuralgic  pains  in,  treatment,  44 

of  hands,  42 

significance  of,  42 

ulcer  of  stomach  as  cause,  47 
Emphysema,  317,  329 

physical  signs,  330 

treatment,  331 
Emprosthotonos  in  tetanus,  224 
Empyema,  331 
Encephalitis,  619 

treatment,  619 
Endocarditis,  272 

benign,  273 

chronic  infective,  277 

in  lobar  pneumonia,  144 

malignant,  276 
treatment,  277 

rheumatic,  187,  273 

simple,  273 
treatment   275 
Endotoxin,  71 

Enlargement  of  veins,  253-256 
Enteralgia,  545 
Enteric  fever,  147 
Enterocolitis,  374 
Enteroptosis,  369 

treatment,  370 
Epidemic  jaundice,  394 

parotitis,  no 

poliomyelitis,  561 
Epilepsy,  523 

convulsions  in,  525 

etiology,  523 

grand  mal,  525 

hystero-,  539 

idiopathic,  529 

infantile,  533 

petit  mal,  525 


Epilepsy,  prophylaxis,  531 

reflex,  529 

sudden  onset,  527 

symptoms,  525 

treatment,  529 

unconsciousness  in,  526 
Epileptiform  convulsions  in  uremia,  433 
Epistaxis,  245,  305 

treatment,  305 
Equilibrium,  534 
Ergot  in  hemophilia,  245 

in  migrainous  headache,  37 

in  periodic  neuralgias,  37 
Erysipelas,  197 

surgical,  199 

treatment,  200 

lobar    pneumonia    and,    clinical    resem- 
blance, 143 

medical,  198 

puerperal,  200 
Erj^throcytes,  240 
Erythromelalgia,  554 
Esophagus,  cancer  of,  631 

diseases  of,  337 

organic  affections,  338 

stricture  of,  337 
Estivo-autumnal  malaria,  212 
Exophthalmic  goiter,  473.     See  also  Graves' 

disease. 
Exotoxin,  71 
Expectorant  cough,  51,  54 

treatment,  55 
Expectoration  in  lobar  pneiunonia,  141 
Eyes,  conjugate  deviation  of,  in  apoplexy 
and  hemiplegia,  609 

diphtheria  of,  102 
Eye-strain,  headache  from,  38 

Facial  nerve,  paralysis  of,  593 

treatment,  594 
Facultative  parasites,  74 
False  aneurysm,  268 

angina  pectoris,  294 
Famine  fever,  206 
Fat  in  urine,  443 

reduction  of,  461 
Fatty  cirrhosis  of  liver,  409 

metamorphosis  in  malignant  tumors,  629 

tumors,  462 
Febrile  anemia,  250 
Feces,  bacteria  in,  372 
Feet,  vasomotor  nerves  of,  20 

wet,  20,  21 


650 


INDEX 


Fenestra  ovalis,  595 
Fermented  milk,  345 
Fetid  stomatitis,  334 
Fever  in  phthisis,  176 

vomiting  in,  63 
Fibrinous  bronchitis,  317 

treatment,  318 
Fibroid  phthisis,  179 
Fibrosis  of  lung,  328 
Fibrositis,  chronic,  297 

treatment,  297 
Fifth  nerve,  diseases,  589 
Filaria  Bancrofti,  443 

bronchialis,  503 

diurna,  503 

hominis  oris,  503 

labialis,  503 

lentis,  503 

loa,  503 

perstans,  503 
Filariasis,  503 

Filix  mas  for  tapeworm,  495 
Filterable  micro-organisms,  75 
Fingers,  dead,  248 
Flatulence  in  Graves'  disease,  480 
Flea,  505 
Flexner's  serum  in  cerebrospinal  meningitis, 

197 
Flies,  invasion  of,  505 

larvse  of,  506 
Follicular  stomatitis,  334 
Foreign  bodies  in  stomach,  361 
Fovea  centralis,  586 
Fragilitas  ossium,  301 
Frankel's  pneumococcus,  139 

treatment  of  walking  in  tabes  dorsalis,  132 
Fresh  air  in  tuberculosis,  171 
Friedlander's  bacillus,  139 
Friedreich's  disease,  624 
Frontal  headache,  36 

treatment,  36 
Functional  medicines,  68 

Gait,  steppage,  in  lead-poisoning,  518 
Gall-bladder,  bacteria  in,  396 

typhoid  bacillus  in,  396 
Gall-stones,  395.     See  also  Cholelithiasis. 
Ganglion,  spinal,  523 
Gangrene  in  measles,  95 

of  lung,  321 
symptoms,  321 
treatment,  321 
Gangrenous  pancreatitis,  418 


Gangrenous  stomatitis,  335 
Gartner's  bacillus,  161 
Gastralgia,  38,  544 

biliary  colic  and,  differentiation,  399 
Gastric  crisis  in  tabes  dorsalis,  128 

neuroses,  544 
Gastritis,  acute,  344 
treatment,  344 

as  cause  of  emaciation,  47 

chronic,  344 
treatment,  345 
medicinal,  346 

pain  in,  30 

phlegmonous,  346 

vomiting  in,  61 
Gastroduodenal  ulcers,  347 
chronic,  351 
treatment,  352 
Gastro-intestinal     disorders     as    cause    of 
emaciation,  47 

symptoms  of  uremia,  434 
Gastroptosis,  369 
Gastros taxis,    361 
Gastrosuccorrhea,  358 
Gelatin  in  ulcer  of  stomach,  352 
Gelsemin  in  trigeminal  neuralgia,  592 
General  paralysis  of  insane,  133 
Generation,  alternate,  496 
German  measles,  96 
Gestures,  significance  of,  24,  25 
Girdle-pain  in  Pott's  disease,  583 
Glands,  tuberculous,  180 
Gleet,  135 

Glenard's  disease,  369 
Glioma  of  brain,  620 
Gliosis  of  spinal  cord,  569 
Glossopharyngeal  nerve,  derangements  of, 

598 
Glottis,  edema  of,  313 
Glycosuria,  452 

alimentary,  456 
Godius,  494 
Goiter,  463 

endemic,  463 

exophthalmic,  473.     See  also  Graves'  dis- 
ease. 
Goitrous  wells,  463 
Gonorrhea,  134 

chordee  in,  135 

clinical  course,  135 

treatment,  137 

urethral  stricture  in,  135 
Gonorrheal  arthritis,  136 


INDEX 


651 


Gonorrheal  rheumatism,  136 
Gout,  447 

treatment,  450 
Gouty  arthritis,  448 

rheumatic  arthritis  and,  differentiation, 
27,  189,  190 
bronchitis,  449 
nephritis,  429 
ophthalmia,  449 
Grand  mal,  525 
Gravel,  435 
Graves'  disease,  473 

acute,  486 

arterial  pulsation  in,  253 

as  cause  of  emaciation,  50 

bulimia  in,  482 

chronicity,  485 

constipation  in,  482 

diarrhea  in,  4,81 

digestive  disturbances  in,  479 

disorders  of  intestine  in,  481 
of  stomach  in,  480 

emaciation  in,  482 

family  complaint,  486 

flatulence  in,  480 

headache  in,  477 

insomnia  in,  482 

irritability  of  bladder  in,  483 

itching  of  skin  in,  483 

loss  of  hair  in,  483 

migraine  in,  478 

morning  symptoms,  484 

nausea  in,  480 

pains  in,  477 

palpitatif^n  of  heart  in,  476 

paresthesia  in,  479 

pathology,  487 

pigmentation  of  skin  in.  483 

pulse  in,  475 

sudden  death  in,  487 

surgical  treatment,  492 

sweating  in,  483 

symptoms,  473 
morning,  484 

tachycardia  in,  475 

thyroidism  in,  493 

treatment,  488 
surgical,  492 

vertigo  in,  479 
Guaiacol  carbonate  in  phthisis,  175 
Guinea-worm  disease,  treatment,  502 
Gumma,  118,  119 

symptoms  produced  by,  121 


Habit,  67 

alcohol,  508 

cannabis  indica,  508 

cocain,  509 

digestion  and,  338 

drug,  507 

hashish,  508 

mescal  button,  509 

opium,  507 
Hair,  changes  in,  in  syphilis,  118 

loss  of,  in  Graves'  disease,  483 
Hair-cells,  596 
Hands,  emaciation  of,  42 
Hanot's  cirrhosis,  411 
Hashish  habit,  508 
Hay-fever,  310 

symptoms,  311 
Headache  from  eye-strain,  38 

frontal,  36 
treatment,  36 

in  cerebral  syphilis,  120 

in  Graves'  disease,  477 

in  tj^jhoid  fever,  149 

migrainous,  37 
ergot  in,  37 

neuralgic,  29 

sick,  550 
Head's  cutaneous  reflex  pains,  41 
Heart  affections,  rheumatic,  187 

bovine,  285 

burn,  341 

diphtheric  affections  of,  treatment,  106 

diseases  of,  272,  273 
pain  in,  30 
primary,  273 
secondary,  273 

fimctional  disorders  of,  291 

in  lobar  pneumonia,  143 

in  scarlet  fever,  91 

in  typhoid  fever,  151,  152 

ossification  of,  274 

palpitation  of,  in  Graves'  disease,  476 

syphilitic  affections,  119 

valvular  disease  of,  as  cause  of  dyspnea,  58 
cough  in,  53 
Heart-block,  259 

Heart-sound,  second,  accentuation  of,  272 
Heat,  66 

dry,  66 

in  amenorrhea,  66 

in  muscular  spasm,  66 

in  rheumatism,  67 

moist,  66 


652 


INDEX 


Heat,  uses  of,  66 
Heatstroke,  611 
Heberden's  nodes,  300 
Hebra's  ointment  in  lupus,  183 
Hematemesis  in  cancer  of  stomach,  633 
Hemic  dyspnea,  58 
Hemiopia,  587 
Hemiplegia,  606 

conjugate  deviation  in,  609 

hemorrhage  in  crus  in,  609 

hysteric,  539 

involvement  of  nerve-trunk  in,  608 

nuclear  paralysis  associated  with,  608 

supranuclear   paralysis   associated   with, 
607 

treatment,  608 
of  late  results,  607 
Hemoglobintiria,  247 

paroxysmal,  247 

treatment,  248 
Hemophilia,  245 

treatment,  245 
Hemorrhage,  245 

in  alcoholic  cirrhosis  of  liver,  408 

in  aortic  aneurysm,  271 

in  crus  in  hemiplegia,  609 

in  typhoid  fever,  150,  152,  155 

pancreatic,  417 
symptoms,  417 
Hemorrhagic  small-pox,  85 
Hemorrhoids,  391 

treatment,  391 
Hemostatic,  cold  as,  65 
Hepatic  calculus,  pain  in,  28 

colic,  34 
Hepatitis,  392 

cough  in,  53 

treatment,  392 
Heroin  in  whooping-cough,  109 
Herpes  zoster,  579 
treatment,  581 
Hiccup,  332 

treatment,  332 
Hip- joint  disease,  pain  in,  27 
His,  auriculoventricular  bundle  of,  259 
Hobnail  liver,  407 
Hodgkin's  disease,  295 

treatment,  296 
Hookworm  disease,  500 

treatment,  502 
Hort's  treatment  of  gastroduodoial  ulcer, 

349 
Hour-glass  stomach,  350,  357 


Hunger,  air-,  in  diabetes,  455 

pain  in  duodenal  ulcer,  351 
Hunterian  chancre,  116 
Hutchinson's  treatment  in  syphilis,  121 
Hyaline  degeneration  in  malignant  tumors, 

629 
Hydatid  cysts,  496 
of  kidney,  445 
of  liver,  413 
treatment,  498 
Hydrocephalus,  619 

acquired,  619 

congenital,  619 

treatment,  620 
Hydronephrosis,  440 
Hydrophobia,  225 

incubation  period,  226 

S3Tnptoms,  226 

treatment,  227 
Hydropnemnothorax,  328 
H3^erchlorhydria,  357 

symptoms,  358 

treatment,  358 
Hyperesthesia,  hysteric,  540 
Hyperpjnrexia  in  rheumatic  fever,  188 
Hypertrophic  cirrhosis  of  liver,  411 

treatment,  411 
Hypertrophy  of  spleen,  415 
Hypoglossal  nerve,  derangements  of,  601 
Hypophysis,  453,  466 
Hysteria,  538 

anesthesia  in,  540 

contractures  in,  540 

hyperesthesia  in,  540 

motor  phenomenon,  539 

treatment,  541 
Hysteric  contractures,  540 

cough,  54 

hemiplegia,  539 

monoplegia,  539 

pains,  40 

paraplegia,  540 

tmnors,  462 
Hystero-epilepsy,  539 

Ice-bag,  use  of,  65 

Icterus,  393.     See  also  Jaundice. 

Idiopathic  tetanus,  224 

Ileus,  369 

Immunity,  71 

to  tuberculosis,  169 
Incus,  595 
Indicanuria,  442 


INDEX 


653 


Indicanuria,  causes,  442 

treatment,  442 
Infantile  convulsions,  533 
treatment,  534 

paralysis,  560.       See  also  Poliomyelitis, 
acute  anterior. 

scurvy,  247 
Infections,  73 

acute,    directly    communicable    or    con- 
tagious, 80 

by  Bacillus  coli,  232 
treatment,  235 

classification  of,  75 

communicable  by  inoculation,  209 
by  intermediate  carriers,  138 

local,  79 

mixed,  77 

multiple,  77 

of  pelves  of  kidney,  438 

surgical,  231 
Infectious  diseases,  75 
Infective  endocarditis,  chronic,  277 
Inflammation,  19 

of  brain,  619 

of  muscles,  623 

treatment,  23 

Inflammatory  pains,  27 

aconite  in,  32 

opium  in,  32 

treatment,  31 

Influenza,  in 

bacillus,  112 

causative  agent,  112 

clinical  features,  in 

mortality  from,  112 

treatment,  113 
Inhibition,  521 
Inoculable  diseases,  76 
Insane,  general  paralysis  of,  133 
Insanity,  uremic,  433 
Insects,  parasitic,  505 
Insolation,  610 
Insomnia  in  Graves'  disease,  482 

in  lobar  pneumonia,  141 
Inspection,  cardiac,  272 

in  aneiuysm  of  aorta,  269 
Insular  sclerosis,  556 
Intention  tremor  in  disseminated  sclerosis, 

558  __ 
Interstitial  nephritis,  chronic,  427 

treatment,  429 
Intestinal  catarrh,  362 

crises  in  tabes  dorsahs,  129 


Intestinal  discharges,  372 

form  of  mycosis  intestinalis,  167 

motility,  367 

tract,  bacteriology  of,  372 

cancer  of,  633 
worms,  494 
as  cause  of  cough,  54 
Intestine,  bacteria  in,  372 
cancer  of,  633 
diseases  of,  361 
as  cause  of  emaciation,  47 
in  Graves'  disease,  481 
tuberculosis  ulceration,  363 
Ipecacuanha  in  amebic  dysentery,  390 
Iron  in  cardiac  debility,  283 
in  chlorosis,  239 
in  diabetes,  458 
Irritability,  vesical,  in  Graves'  disease,  483 
Irritant  cough,  51 

varieties,  51,  52 
Irritation  of  cervix  uteri  as  cause  of  cough, 

54 
of  external  meatus  of   ear  as  cause  of 

cough,  53 
Islands  of  Langerhans,  416 
Itch,  504 
Itching  of  skin  in  Graves'  disease,  483 

Jail  fever,  97 
Jaimdice,  393 

catarrhal,  394 

causes,  394 

epidemic,  394 

in  newborn,  394 

treatment,  395 
Jiggers,  505 
Joints,  affections  of,  in  tabes  dorsalis,  1 29 

diseases  of,  297 

Kala-azar,  229 

symptoms,  230 

treatment,  230 
Kemig's  sign  in  cerebrospinal  meningitis, 

197 
Kidney  affections  in  diphtheria,  104,  106 

amyloid  degeneration,  414 

cysts  of,  445 

diseases  of,  420 

displacement  of,  446 

hydatid  cysts,  445 

large  white,  423 

movable,  446 

pelves  of,  infection,  438 


654 


INDEX 


Kidney,  polycystic  disease,  445 

red,  contracted,  425 

stone  in,  435 

tumors  of,  445 

white,  small  contracted,  425 
Klebs-Loffler  bacillus,  100 
Knee-jerk,  loss  of,  in  tabes  dorsalis,  126 
Knife-grinders'  phthisis,  303 
Koplik's  spots  in  measles,  93 
Koumiss,  345 

Labyrinth,  595 

La  grippe,  iii.     See  also  Influenza. 

Landry's  paralysis,  581 

Langerhans,  islands  of,  416 

Lardaceous  liver,  414 

Large  white  kidney,  423 

Larvae  of  flies,  506 

Laryngeal  crises  in  tabes  dorsalis,  1 29 

diphtheria,  104 

nerve,  inferior,  598 

paralysis,  599 
Laryngismus  stridulus,  314 
Laryngitis,  acute,  312 
treatment,  312 

chronic,  313 

tubercular,  179,  313 
treatment,  180,  314 
Larynx,  muscles  of,  spasm,  599 
Lateral  sclerosis,  555 
Lavage  of  bladder  in  chronic  cystitis,  438 

of  stomach,  341 

in  chronic  gastritis,  346 
Laville's  extract  in  gout,  451 
Law,  CoUes',  120 

Courvoisier's,  in  gall-stones,  400 
Lead-colic,  517 
Lead-palsy,  517 
Lead-poisoning,  515 

blue  line  in,  517 

colic  of,  517 

pain  in,  38,  516 

paralysis  in,  517 

steppage  gait  in,  518 

symptoms,  516 

treatment,  518 

wrist-drop  in,  517 
Leg,  milk,  254 

varicose  veins  of,  254 
Leprosy,  184 

anesthetic,  185 

bacillus,  184 

nodular,  185 


Leprosy,  symptoms,  185 

treatment,  185 

Leukemia,  splenomedullary,  243 

symptoms,  243 

treatment,  245 

Leukoplakia,  235 

Lightning  pains  in  tabes  dorsalis,  125,  127 
Linseed  oil  in  acute  bronchitis,  316 
Lipemia  in  diabetes,  455 
Lithuria,  443 
Liver,  abscess  of,  412 

in  amebic  dysentery,  389 
acute  yellow  atrophy,  413 
amyloid  degeneration,  414 

treatment,  414 
cancer  of,  634 
cirrhosis  of,  406 
alcoholic,  406 
s5Tnptoms,  408 
treatment,  409 
as  cause  of  emaciation,  50 
fatty,  409 
hypertrophic,  411 
treatment,  411 
in  children,  410 
syphilitic,  409 
compensatory  circulation,  407 
diseases  of,  392 
hobnail,  407 
hydatid  cyst,  413 
lardaceous,  414 
movable,  414 
waxy,  414 
Lobar  pneumonia  ,138.   See  al  so  Pneumonia , 

lobar. 
Lockjaw,  221.     See  also  Tetanus. 
Locomotor    ataxia,    124.     See    also    Tabes 

dorsalis. 
Louse,  505 
Lousiness,  505 
Lumbar  plexus,  affections  of,  575 

puncture  in  vertigo,  536 
Lung,  abscess  of,  331 
cancer  of,  635 
cirrhosis  of,  328 

treatment,  329 

fibrosis  of,  328 

gangrene  of,  321 

symptoms,  321 

treatment,  321 

Lupus,  182 

treatment,  183 
Lymphatics,  diseases  of,  295 


INDEX 


655 


Lymphatics,  tuberculous,  180 
Lymphatism,  466 
Lysis,  75 

Malaria,  209 

estivo-autumnal,  212 
mosquitoes  and,  210 
quartan,  211 
symptoms,  211 
tertian,  211 
treatment,  213 
Malignant  diseases,  626 

as  cause  of  emaciation,  46 
autositic,  628 

colloid  degeneration  in,  629 
fatty  metamorphosis  in,  629 
hyaline  degeneration  in,  629 
metastasis  of,  628 
origin  and  nature,  629,  630 
radium  in,  638 
treatment,  638 
endocarditis,  276 
treatment,  277 
measles,  94 
pustule,  166 
scarlet  fever,  87 
small-pox,  85 
Malleus,  595 
Malta  fever,  207 

treatment,  208 
Mammary  cancer,  635 
McBurney's  point,  28,  377 
Measles,  93 
black,  94 

bronchopneumonia  in,  94 
clinical  cours^,  93 
complications,  94 

convalescence  from,  care  during,  23 
diarrhea  in,  95 
gangrene  in,  95 
German,  96 
incubation  period,  93 
Koplik's  spots  in,  93 
malignant,  94 
otitis  media  in,  94 
pleurisy  in,  94 
pneumonia  in,  94 
treatment,  95 
Meat-poisoning,  161 
Median  paralysis,  575 
Medicinal  remedies,  68 
Medicine,  68 

constitutional,  68 


Medicine,  functional,  68 
Mediterranean  fever,  207 
Melancholia,  546 
Melanuria,  445 
Membranous  colitis,  379 
Meniere's  disease,  536 
Meningitis,  cerebrospinal,   195.       See  also 
Cerebrospinal  meningilis. 

tuberculous,  181 
treatment,  182 
vomiting  in,  63 
Mental  interest,  digestion  and,  339 
Meralgia  paraesthetica,  576 
Mercurial  stomatitis,  335 
Mescal  button  habit,  509 
Metabolism,  diseases  of,  447 
Metamorphosis,  fatty,  in  malignant  tumors, 

629 
Metastasis  of  malignant  growths,  628 
Micrococcus  melitensis,  207 
Micro-organisms,  73 

entrance  into  body,  75 

filterable,  75 

method  of  leaving  body,  76,  79 

ultramicroscopic,  75 

virulence  of,  76 
Microtic  aneurysm,  268 
Migraine,  549 

in  Graves'  disease,  478 

sjrmptoms,  549 

treatment,  550 
Migrainous  headache,  37 

ergot  in,  37 
Miliary  aneurysm,  267 

tuberculosis,  168 
Milk,  fermented,  345 

leg,  254 
Mineral  poisons,  515 
Mitral  regurgitation,  288 
treatment,  290 

stenosis,  287 
murmur  in,  287 
treatment,  288 
Moist  heat,  66 
Monoplegia,  hysteric,  539 
Morphinism,  507 
Morvan's  disease,  571 
Mosquitoes,  malaria  and,  210 

yellow  fever  and,  219 
Moth,  brown-tail,  506 

yellow-tail,  506 
Motility,  intestinal,  367 
Motor  phenomena  of  hysteria,  539 


6s6 


INDEX 


Mouth,  sore,  putrid,  334 
Movable  kidney,  446 

liver,  414 
Mucous  colitis,  379 
S3miptoms,  382 
treatment,  383 

membranes,  lesions  of,  in  syphilis,  118 

patches  in  sj^hilis,  118 
Muguet,  sss 
Miunps,  no 

orchitis  in,  no 

otitis  media  in,  no 

treatment,  no 
Murmur  in  aortic  regurgitation,  286 

in  mitral  stenosis,  287 
Muscles,  diseases  of,  623 

inflammation  of,  623 

of  larynx,  spasm,  599 
Muscular  atrophy,  44 
progressive,  566 

pain  in  Graves'  disease,  477 

rhetmiatism,  chronic,  297 
pain  in,  27 

spasm,  heat  in,  66 
Musculospiral  paralysis,  574 
Myalgia,  625 

pain  in,  34 

treatment,  34,  625 
Myasthenia  gravis,  624 
Mycosis  intestinalis,  intestinal  form,  167 
Myelitis,  581 

bed-sores  in,  582 
Myoma,  627 
Myosarcoma,  629 
Myositis,  623 
Myotonia,  624 
Myxedema,  464 

Nails,  changes  in,  in  syphilis,  118 
Nape  of  neck,  nerves  at,  20 
Narcotin  in  malaria,  218 
Nasal  catarrh  from  catching  cold,  20 

treatment,  22 
Nausea  in  Graves'  disease,  480 
Necator  americanus,  500 
Neck,  Derbyshire,  463 

nape  of,  nerves  at,  20 
Necrosis,  phosphorus,  302 
Negri  bodies,  225 
Nematodes,  rare,  503 
Neosalvarsan  in  syphilis,  124 
Nephritis,  acute,  420 
causes  of,  421 


Nephritis,  acute,  from  catching  cold,  422 

in  scarlet  fever,  421 

treatment  422 
chronic,  423 

desquamative,  423 

diffuse,  with  exudation,  424 

interstitial,  427 

treatment,  429 

parench)Tnatous,  423 

sjonptoms,  423 

treatment,  426 

tubal,  423 
dropsy  of,  60 
gouty,  429 
in  diphtheria,  104 

treatment,  107 
in  syphilis,  119 
in  typhoid  fever,  158 
pain  of,  38 
scarlatinal,  91 
Nephrolithiasis,  435 
Nerve,  acoustic,  595 

auditory,  affections  of,  594 

circiunflex,  injury  of,  paralysis  after,  573 

cutaneous,  external,  injury  of,  paralysis 

after,  576 
eighth,  595 
facial,  paralysis  of,  593 

treatment,  594 
fifth,  diseases  of,  589 
glossopharyngeal,  derangements  of,  598 
hypoglossal,  derangements  of,  601 
laryngeal,  superior,  598 
median,  injury  of,  paralysis  after,  575 
musculospiral,  injury  of,  paralysis  after, 

574 
ninth,  derangements  of,  598 
obtiu-ator,  injury  of,  paralysis  after,  575 
optic,  diseases  of,  586 
pneumogastric,  cardiac  branches,  derange- 
ments of,  599 

derangements  of,  598 

laryngeal  branches,  derangements  of, 
598 

paralysis  due  to  involvement  of,  598 
popliteal,   external,   injury  of,   paralysis 
after,  577 

internal,  injury  of,  paralysis  after,  577 
radial,  injury  of,  paralysis  after,  574 
sciatic,  injury  of,  paralysis  after,  577 
seventh,  derangements  of,  594 
spinal  accessory,  derangements  of,  600 
tenth,  derangements  of,  598 


INDEX 


657 


Nerve,   thoracic,  long,  injury  of,   paralysis 
after,  573 
trigeminus,  diseases  of,  589 
ulnar,  injury  of,  paralysis  after,  574 
vestibular,  595 
Nerves  at  nape  of  neck,  20 
cranial,  diseases  of,  586 
olfactory,  diseases  of,  586 
tumors  of,  622 
vasomotor,  of  feet,  20 

relation  of,  to  catching  cold,  18 
susceptibility  of,  to  cold,  20 
Nervines,  69 

Nervous  diseases,  functional,  523 
organic,  555 
symptoms  in  typhoid  fever,  151 
system,  diseases  of,  520 
Neuralgia,  35 

brachial,  pain  of,  35 
cervico-occipital,  35 
definition  of,  545 
periodic,  ergot  in,  37 
supra-orbital,  591 
toxic,  non-febrile,  36 
trigeminal,  545,  590 
pain  of,  35 
treatment,  591 
Neuralgic  headache,  29 
pains,  26,  27,  29,  35 
in  anemia,  39 

in  emaciation,  treatment,  44 
non- toxic,  38 
toxic,  febrile,  36 
non-febrile,  36,  38 
Neurasthenia,  5.' 7 
treatment,  548 
Neiu-itis,  583 
alcoholic,  583 
brachial,  572 
etiology,  583 
optic,  588 
peripheral,  in  typhoid  fever,  157 

pain  in,  27 
treatment,  584 
Neuroma,  622 

treatment,  622 
Neuron,  definition  of,  520 

independence  of,  521 
Neuronophagia,  562 
Neuroses,  gastric,  544 
Neurotic  angina  pectoris,  294 
New  growths,  626 
Newborn,  icterus  in,  394 
42 


Night-sweats  in  phthisis,  treatment,  174 

Ninth  nerve,  derangements  of,  598 

Nitrites  in  arterioscleorsis,  265 

Nitroglycerin  in  angina  pectoris,  293 
in  arteriosclerosis,  2C5 

Nits,  505 

Nodes,  Heberden's,  300 
of  Ranvicr,  556 

Nodular  leprosy,  185 

Noma,  335 

Nose,  304 

Nosebleed,  305 

Nuclear    paralysis    associated    with    hemi- 
plegia, 608 

Obesitv,  461 

treatment,  462 
Objective  pains,  40 
Obligate  parasites,  74 
Obstetric  palsy,  573 
Obturator  paralysis,  575 
Oidium  albicans,  333 
Oil,  castor,  in  mucous  colitis,  384 

cod-liver,  in  diabetes,  458 
in  phthisis,  175 
in  rickets,  461 

inunction  in  phthisis,  1 74 

linseed,  in  acute  bronchitis,  316 

oKve,  in  cholelithiasis,  402 
Olfactory  nerves,  diseases,  586 
Olive  oil  in  cholelithiasis,  402 
Oliver's  sign  in  aortic  aneurysm,  270 
Ophthalmia,  gouty,  449 
Opisthotonos  in  tetanus,  224 
Opium,  68,  69 

habit,  507 

in  diabetes,  457 

in  gangrene  of  lung,  321 

in  inflammatory  pains,  32 

in  malaria,  217,  218 

in  peritonitis,  364,  366 
Opsonins,  71 
Optic  atrophy,  588 

in  tabes  dorsalis,  128 

nerve  diseases,  586 

neuritis,  588 

tract,  diseases,  586 
Oral  sepsis,  335 

Orbicularis  muscle,  spasm  of,  594 
Orchitis  in  mumps,  no 
Orthopnea,  58 
Ossification  of  heart,  274 
Osteitis  deformans,  300 


658 


INDEX 


Osteo-arthropathy,  pulmonary,  301 
Osteomalacia,  301 
Otitis  media,  596 

in  measles,  94 

in  mumps,  no 

in  scarlet  fever,  89 
Oxaluria,  435 
Oxyuris  vermicularis,  499,  500 

Pain,  anginose,  39 
burning,  30 
cutaneous  reflex,  27,  41 
girdle-,  in  Pott's  disease,  583 
hunger,  in  duodenal  ulcer,  351 
hysteric,  40 

in  aortic  aneurysm,  271 
in  appendicitis,  28,  377 
in  brachial  neuralgia,  35 
in  Bright's  disease,  38 
in  cancer  of  stomach,  633 
in  cholelithiasis,  397-400 
in  cramps,  33 
in  gastritis,  30 
in  Graves'  disease,  477 
in  heart  disease,  30 
in  hepatic  calculus,  28 
in  hip-joint  disease,  27 
in  lead-poisoning,  38,  516 
in  lobar  pneumonia,  140 
in  muscular  rheumatism,  27 
in  myalgia,  34 
in  peripheral  neuritis,  27 
in  pleurisy,  323 
in  pneumonia,  30 
in  renal  calculus,  28 
in  sciatica,  27 
in  sprains,  34 
in  tabes,  treatment,  38 
in  tic  douloureux,  35 
in  trigeminal  neuralgia,  35 
inflammatory,  27 

aconite  in,  32 

opium  in,  32 

treatment,  31 
lightning,  in  tabes  dorsalis,  125,  127 
neuralgic,  26,  27,  29,  35 

in  anemia,  39 

in  emaciation,  treatment,  44 

non- toxic,  38 

toxic,  febrile,  36 
non-febrile,  36,  38 
objective,  40 
pressure,  27,  32 


Pain,  pressure,  treatment,  33 
significance  of,  24 
stretching,  26,  27,  34 
subjective,  26,  27,  40 
Palpalis  gambiense,  228 

morsitans,  228 
Palpation  in  aortic  aneurysm,  270 
cardiac,  272 
in  pleurisy,  325 
of  radial  artery,  249 
Palpitation  of  heart  in  Graves'  disease,  476 
Palsy.     See  Paralysis. 
Pancreas,  autodigestion  of,  416 
cancer  of,  635 
diseases  of,  416 
secretion  of,  416 
Pancreatic  abscess,  418 
calculi,  419 
cyst,  419 
hemorrhage,  417 
symptoms,  417 
secretion,  416 
Pancreatitis,  acute,  418 
chronic,  419 
gangrenous,  418 
Paralysis,  abductor,  bilateral,  599 
unilateral,  599 
adductor,  599 

after  injury  of  circumflex  nerve,  573 
of  external  cutaneous  nerve,  576 

popliteal  nerve,  577 
of  internal  popliteal  nerve,  577 
of  long  thoracic  nerve,  573 
of  median  nerve,  575 
of  musculospiral  nerve,  574 
of  obturator  nerve,  575 
of  radial  nerve,  574 
of  sciatic  nerve,  577 
of  ulnar  nerve,  574 
agitans,  541 

symptoms,  542 
alternating,  608 
atrophic  chronic,  566 
Bell's,  593 
brachial,  572 
bulbar,  568 
chronic  atrophic,  566 
crossed,  608 
diphtheric,  103 

treatment,  106 
due    to    involvement    of    pneumogastric 
nerve,  598 
of  spinal  accessory  nerve,  600 


INDEX 


659 


Paralysis,  general,  of  insane,  133 

infantile,   560.        See  also  Poliomyclilis, 

acule  anlerior. 
Landry's,  581 
laryngeal,  599 
lead-,  517 

nuclear,  associated  with  hemiplegia,  608 
obstetric,  573 
of  facial  nerve,  593 
treatment,  594 
of  vagus,  600 
serratus,  573 
shaking,  541 
supranuclear,  associated  with  hemiplegia, 

607 
trapezius,  573 
Paraphasia,  617 
Paraplegia,  hysteric,  547 
Parasites,  animal,  diseases  caused  by,  494 
facultative,  74 
obligate,  74 
Parasitic  arachnids,  504 
insects,  505 
stomatitis,  334 
Parasyphilitic  affections,  124 
Parathyroids,  465 
Paratyphoid  fever,  161 
Paregoric  in  malaria,  217 
Parenchymatous  nephritis,  chronic,  423 

treatment,  426 
Paresis,  133 

Paresthesia  in  Graves'  disease,  479 
Parkinson's  disease,  541 
Parotitis,  epidemic,  no 
Paroxysmal  hemoglobinuria,  247 
tachycardia,  291 
treatment,  291 
Pectoriloquy  in  phthisis,  178 
Pediculosis,  505 
Pediculus  capitis,  505 
Peliosis  rheumatica,  190 
Pellagra,  204 
symptoms,  205 
treatment,  205 
Pelves  of  kidney,  infection,  438 
Peptic  asthma,  308 
Percussion,  cardiac,  272 

in  aortic  aneurysm,  270 
Perforation  in  typhoid  fever,  150,  152,  156 
Pericarditis,  278 
dyspnea  in,  57 
in  pneumonia,  144,  280 
rheumatic,  188,  278 


Pericarditis,  treatment,  280 
Perihepatitis,  392 
Perinephric  abscess,  441 

treatment,  442 
Peri-pericarditis,  281 
Peritonitis,  364 
in  children,  366 
symptoms,  364 
trc-atment,  366 
Pernicious  anemia,  241 
arsenic  in,  243 
clinical  course,  241 
etiology,  242 
treatment,  243 
Pertussis,  107 
bronchitis  in,  108 
bronchopneumonia  in,  108 
convalescence  from,  care  during,  23 
cough  in,  53 
symptoms,  108 
treatment,  108 
Pestis,  80 
Petit  mal,  525 
Phlebitis  in  typhoid  fever.  157 

localized,  253 
Phlegmasia  alba  dolens,  254 
Phlegmonous  gastritis,  346 
Phosphatic  calculus  in  bladder,  436 
Phosphaturia,  443 
Phosphorus  in  lupus,  183 

necrosis,  302 
Phthisis,  167 

bronchophony  in,  178 
care  of  skin  in,  173,  174 
cod-liver  oil  in,  175 
cough  in,  177 
diet  in,  172 

examination  of  chest  in,  177 
emaciation  in,  45,  46,  177 
fever  in,  176 
fibroid,  179 
fresh  air  in,  171 
knife-grinders',  303 
night-sweats  in,  treatment,  174 
oily  inunctions  in,  174 
pectoriloquy  in,  178 
pulse  in,  176 
rales  in,  178 
stone-cutters',  303 
symptoms,  176 
temperature  in,  176 
treatment,  170 
medicinal,  174 


66o 


INDEX 


Phthisis,  tuberculous  laryngitis  in,  179 

Pigeon  breast,  461 

Pigmentation  of  skin  in  Graves'  disease,  483 

Piles,  391 

Pinna,  594 

Pin- worms,  499,  500 

Piroplasma  bigeminum,  210 

Pituitary  gland,  453 

diseases,  466 
Plague,  80 

bacillus,  80 

buboes  in,  treatment,  83 

bubonic,  82 

pneumonic,  82 

rats  in  transmission  of,  80,  81 

septicemia,  82 

treatment,  83 
Pleurisy,  322 

acute  cough  in,  52 

aspiration  in,  326 

cough  in,  323 

duration,  325 

effusion  in,  324 

egophony  in,  323 

in  measles,  94 

in  scarlet  fever,  91 

pain  in,  323 

palpation  in,  325 

pleurodjTiia  and,  diiJerentiation,  29 

rales  in,  324 

rheiunatic,  327 

Skoda's  resonance  in,  325 

symptoms,  323 

treatment,  325 

vocal  resonance  in,  323 
Pleuritis,  322.     See  also  Pleurisy. 
Pleurodjmia,  323 

pleurisy  and,  differentiation,  29 
Pleurosthotonos  in  tetanus,  224 
Plexus,  brachial,  affections  of,  572 

lumbar,  affections  of,  575 

sacral,  affections  of,  576 
Pnemnococcus,  138 

Pneumogastric  nerve,  cardiac  branches,  de- 
rangements of,  599 
derangements  of,  598 
laryngeal   branches,   derangements   of, 

598 
paralysis  due  to  involvement  of,  598 
Pneumokoniosis,  302 
Pneumonia,  emaciation  in,  45 

in  measles,  94 

in  scarlet  fever,  91 


Pneumonia,  lobar,  138 

anatomic  changes,  142 

auscultation  in,  142 

burning  heat  of  skin  in,  140 

clinical  covirse,  139 

cough  in,  140 

crackle  in,  143 

crisis  in,  142        . 

delirium  in,  141 

dyspnea  in,  140 

endocarditis  in,  144 

erysipelas    and,    clinical    resemblance, 

143 
expectoration  in,  141 
heart  in,  143 

in  typhoid  fever,  151,  156 
insomnia  in,  141 
pain  in,  140 
pericarditis  in,  144 
pulse  in,  141,  143 
respiration  in,  141 
respiratory  symptoms,  141 
sputvmi  in,  141 
stage  of  gray  hepatization,  142 

of  red  hepatization,  142 
treatment,  144 
vomiting  in,  140 
pain  in,  30 
pericarditis  in,  280 
senile,  143 
Pneumonic  crackle,  143 

plague,  82 
Pneumothorax,  327 
Poikilocytosis,  241 
Point,  McBurney's,  28 
Poison,  artistic,  509 
Poisoning,  arsenic-,  519 

lead-,  515.     See  also  Lead-poisoning. 
meat-,  161 
Poisons,  artistic,  509 
drug,  507 
mineral,  515 
Poliomyelitis,  acute  anterior,  560 
epidemic,  -561 
sporadic,  561 
treatment,  565 
chronic  anterior,  566 
treatment,  568 
Polycystic  disease  of  kidney,  445 
Polycythemia,  415 
Polyuria,  252 

in  chronic  interstitial  nephritis,  429 
Popliteal  aneurysm,  271 


INDEX 


66  X 


Popliteal  nerve,  external,  injury  of,  paralysis 
after,  577 
internal,  injury  of,  [jaralysis  after,  577 
Potassium  bromid  in  tetanus,  225 

iodid  in  actinomycosis,  206 
Pot-belly,  370 
Pott's  disease,  582 
Pressure  pains,  27,  32 

treatment,  33 
Progressive  muscular  atrophy,  568 
Prolapse  of  abdominal  organs,  369 
Proteins  in  diabetes,  454 
Protozoa,  75 
Psammoma,  638 

of  brain,  621 
Ptyalism,  335 
Puerperal  erysipelas,  200 

fever,  201,  365 
Pulex  irritans,  505 
Pulmonary  dyspnea,  56 

gangrene,  321 

osteo-arthropathy,  301 

tuberculosis,  167.     See  also  Phthisis. 
Pulsation,  arterial,  251 

in  abdominal  cavity,  251 
in  Graves'  disease,  253 

in  aneurysm  of  abdominal  aorta,  271 

venous,  256 
Pulse,  257 

compressible,  258 

Corrigan,  285 

duration,  259 

frequency,  258 

hard,  258 

in  appendicitis,  378 

in  Graves'  disease,  475 

in  lobar  pneumonia,  141,  143 

in  phthisis,  176 

in  scarlet  fever,  89 

in  typhoid  fever,  150 

incompressible,  258 

intermittent,  259 

irregular,  259 

large,  259 

long,  259 

rapid,  258 

rhythm,  259 

short,  259 

size,  259 

slow,  258,  281 

small,  259 

soft,  258 

strength,  258 


Pulse  tension.  259 

water-hammer,  285 
Pumpkin  seeds  in  tapeworm,  495 
Puncture,  lumbar,  in  vertigo,  536 
Purin  bodies,  435,  447 
Purpura,  247 

Pustular  small-pox,  symptoms,  85 
Pustule,  malignant,  166 
Putrid  sore  mouth,  334 

vomiting,  treatment,  62 
Pyelitis,  438 

treatment,  439 
Pyemia,  202 
Pylephlebitis,  412 

QuarTjVN  malaria,  211 
Quinin  in  malaria,  214 

Rabiks,  225 
Rachitis,  460 

treatment,  461 
Radial  arter>%  palpation  of,  249 

paralysis,  574 
Radium  in  malignant  diseases,  638 
Railroad  dyspeptics,  339 
Rales  in  phthisis,  178 

in  pleurisy,  324 
Ranvier,  nodes  of,  556 
Rash  of  typhoid  fever,  152 
Rats  in  transmission  of  plague,  80,  81 
Raynaud's  disease,  553 

treatment,  554 
Rectum,  cancer  of,  634 

ulcers  of,  390 
Red  kidney,  contracted,  425 
Refiex,  Babinski's,  607 
Regulin  in  constipation,  369 
Regurgitation,  aortic,  285 
murmur  in,  286 
treatment,  286 

mitral,  288 
treatment,  290 
Relapses  in  typhoid  fever,  150,  157 
Relapsing  fever,  206 
s3rmptoms,  206 
treatment,  207 
Remedies,  65 

constitutional,  68 

functional,  68 

medicinal,  68 

non-medicinal,  64 
Remittent  fever,  bilious,  213 
Renal  calculus,  pain  in,  28 


662 


INDEX 


Renal  colic,  34 
treatment,  34 
dropsy,  60 
Resonance,  Skoda's,  in  pleurisy,  325 

vocal,  in  pleurisy,  323 
Respiration  in  lobar  pneumonia,  141 
Respiratory  symptoms  in  lobar  pneumonia, 
141 
tract,  catarrh  of,  from  catching  cold,  20 
diseases,  303 
Restoratives,  70 
Retina,  586 

Retinitis,  albuminuric,  587 
Revaccination,  83 
Rhabdonema  intestinalis,  504 
Rheumatic  arthritis,  186 

gouty  arthritis  and,  differentiation,  27, 
i8g,  190 
endocarditis,  187,  273 
fever,  186 

alkaline  treatment,  191 
douching  throat  as  preventive,  192 
heart  affections  in,  187 
hyperpyrexia  in,  188 
pericarditis  in,  278 
salicylates  in,  191 
subcutaneous  nodules  in,  190 
sweating  in,  190 
symptoms,  189 
tonsillitis  as  precursor,  189 
treatment,  190 
heart  affections,  187 
pericarditis,  188 
pleurisy,  327 
valvulitis,  273,  274 
Rheumatism,  gonorrheal,  136 
heat  in,  67 
muscular,  chronic,  297 

pain  in,  27 
scarlatinal,  91 
Rheumatoid  arthritis,  299 
etiology,  299 
treatment,  301 
Rhinorrhea  in  scarlet  fever,  88 
Ribbert's  theory  of  origin  and  nature  of 

malignant  growths,  629 
Rice-water  discharges  in  Asiatic  cholera,  163 
Rickets,  460 

treatment,  461 
Rickety  rosary,  461 
Ringing  in  ears,  597 
Risus  sardonicus  in  tetanus,  224 
Rocky  Mountain  fever,  230 


Rocky  Mountain  fever,  symptoms,  231 

treatment,  231 
Rosary,  rickety,  461 
Rose  cold,  311 

Rose's  belt  in  enteroptosis,  371 
Rose-spots  in  typhoid  fever,  152 
Round  worms,  499 
Rubella,  96 
Rupia  syphilitica,  118 

Saccharomyces  albicans,  333 
Saccular  aneurysm,  267 
Sacral  plexus,  affections  of,  576 
Salicylates  in  rheumatic  fever,  191 
Salt  solution  in  acute  nephritis,  423 
Salvarsan  in  kala-azar,  230 

in  syphilis,  123 
Saprophytes,  74 
Sarcoma,  627,  628,  636 
radium  in,  638 
treatment  638 
Scabies,  504 

Scanning  voice  in  disseminated  sclerosis,  557 
Scarlatina  87.     See  also  Scarlet  fever. 

sine  eruptione,  88 
Scarlet  fever,  87 

acute  nephritis  in,  421 

angina  ulcerosa  in,  88 

arthritis  in,  91 

bronchopneumonia  in,  91 

carriers,  89 

complications,  91 

desquamation  in,  89 

eruption  of,  87,  88 

heart  in,  91 

incubation  period,  89 

infectivity,  90 

malignant,  87 

nephritis  in,  91 

otitis  media  in,  89 

pleurisy  in,  91 

pneumonia  in,  91 

pulse  in,  89 

rheumatism  in,  91 

rhinorrhea  in,  88 

symptoms,  87 

strawberry  tongue  in,  88 

treatment,  91 
Schonlein's  peliosis  rheumatica,  190 
Schwann,  sheath  of,  556 
Sciatic  nerve,  injury  of,  paralysis  after.  577 
Sciatica,  577 
pain  in,  27 


INDEX 


663 


Sciatica,  symptoms,  578 

treatment,  578 
Scirrhus,  628 
Scleroderma,  461 

thjTToid  tablets  in,  461 
Sclerosis,  amyotrophic  lateral,  559 
symptoms,  55Q 
treatment,  560 
arteriorenal,  431 
treatment,  432 
disseminated,  556 

intention  tremor  in,  558 
scanning  voice  in,  557 
symptoms,  557 
treatment,  558 
vascillation  in,  558 
insular,  556 
lateral,  555 
symptoms,  555 
treatment,  556 
Scrofula,  180 
Scurvy,  246 
infantile,  247 
sjonptoms,  246 
Secretin,  339 
Sella  turcica,  466 
Senile  pneumonia,  143 
Sepsis,  oral,  335 
Septicemia,  plague,  82 
Serous  apoplexy,  613 
Serratus  paralysis,  573 
Serum,  Flexner's,  in  cerebrospinal  meningi- 
tis, 197 
therapy,  70 
Seventh  nen'e,  derangements  of,  594 
Shaking  palsy,  541 
Sheath  of  Schwann,  556 
Shingles,  579 
Sick  headache,  550 

Sign,  Argyll-Robertson,  in  tabes  dorsalis, 
126 
Kernig's,  in  cerebrospinal  meningitis,  197 
Oliver's,  in  aortic  aneurysm,  270 
Silver  nitrate  in  degenerative   diseases  of 
spine,  132 
to  prevent  scars  in  small-pox,  86 
Skin,  burning  heat  of,  in  lobar  pneumonia, 
140 
care  of,  in  phthisis,  173,  174 
itching  of,  in  Graves'  disease,  483 
pathology  of  chill  aflfecting  localized  areas 

of,  17 
pigmentation  of,  in  Graves'  disease,  483 


Skin,  smarting,  204 

tuberculosis  of,  182 
treatment,  183 
Skoda's  resonance  in  pleurisy,  325 
Sleeping  sickness,  227 

treatment,  229 
Small  white  kidney,  425 
Small-pox,  83 

black,  85 

carbuncles  after,  86 

clinical  course,  84 

confluent,  symptoms,  86 

hemorrhagic,  85 

incubation  period,  84 

malignant,  85 

pustular,  symptoms,  85 

scars  in,  silver  nitrate  to  prevent,  86 

secondary  stage,  84 

syphiloderm  and,  differentiation,  118 

treatment,  87 
Smarting  skin,  204 
Smell,  sense  of,  586 

Sodium  sulphate  in  bacillary  dysentery,  388 
Sore  mouth,  putrid,  334 

throat,  clergyman's,  313 
Sour  stomach,  341 
Spasm,  muscular,  heat  in,  66 

of  muscles  of  larynx,  599 

of  orbicularis  muscle,  594 
Spasmodic  croup,  314 

vATy-neck,  600 
Speech,  602,  613 
Speech-centers,  613,  614 
Spinal  accessory  nerve,  derangements  of,  600 

cord,  522 

gliosis  of,  569 

degeneration  in  tabes  dorsalis,  130 

ganglion,  523 
Spine,  tuberculosis  of,  582 
Spirochaeta  palhda,  115,  123 
Spleen,  diseases  of,  415 

hypertrophy  of,  415 
Splenomedullary  leukemia,  243 
Sporadic  poliomyelitis,  561 
Spots,  Koplik's,  in  measles,  93 
Spotted  fever,  196 
Sprains,  pain  in,  34 
treatment,  34 
Sputum  in  lobar  pneumonia,  141 
Stapes,  595 
Staphylococci,  74 

Starvation  treatment  of  gastric  ulcer,  352 
Status  lymphaticus,  466 


664 


INDEX 


Stegomyia,  219         . 
Stenosis,  aortic,  284 
treatment,  284 
mitral,  287 

murmur  in,  287 
treatment,  288 
of  bile-ducts,  401 
Steppage  gait  in  lead-poisoning,  518 
Stercoraceous  vomiting,  treatment,  62 
Stimulants  of  gland  secretions,  69 
Stock  vaccine,  72 
Stokes-Adams'  disease,  259 
Stomach,  autodigestion  of,  347 
cancer  of,  631 
as  cause  of  emaciation,  46,  47 
changes  in  stomach,  632 
coffee-ground  hematemesis  in,  633 
hematemesis  in,  633 
morbid  anatomy,  631 
pain  in,  633 
symptoms,  632 
vomiting  in,  62 
dilatation  of,  acute,  355 
treatment,  355 
chronic,  355 
treatment,  356 
diseases  of,  338 

as  cause  of  emaciation,  47 
in  Graves'  disease,  480 
foreign  bodies  in,  361 
hour-glass,  350,  357 
lavage  of,  341 

in  chronic  gastritis,  346 
mucous  membrane  of,  atrophy,  360 
neuroses,  544 
sour,  341 
ulcer  of,  347 

as  cause  of  emaciation,  47 
treatment,  352 
vomiting  in,  61 
imdigested  contents  in,  as  cause  of  cough, 

54 
Stomatitis,  333,  334 

aphthous,  334 

fetid,  334 

follicular,  334 

gangrenous,  335 

mercurial,  335 

parasitic,  334 

ulcerative,  334 

vesicular,  334 
Stone-cutters'  phthisis,  303 
Strawberry  tongue  in  scarlet  fever,  88 


Streptococci,  74 
Streptothrix  actinomyces,  206 
Stretching  pains,  26,  27,  34 
Stricture  of  esophagus,  337 

urethral,  in  gonorrhea,  135 
Strongyloides  intestinalis,  504 
Strychnin,  69 
St.  Vitus'  dance,  192 
Subjective  pains,  26,  27,  40 
Sudden  onset  of  epilepsy,  527 
Sulphonal  cyanosis,  248 
Sunstroke,  610 

after-effects  of,  612 
Suppurating  buboes,  125 
Supranuclear  paralysis  associated  with  hemi- 
plegia, 607 
Supra-orbital  neuralgia,  591 
Suprarenal  extract  in  epistaxis,  246 
Surgical  erysipelas,  199 

infections,  231 
Sweating  in  acute  nephritis,  423 

in  Graves'  disease,  483 

in  rhetmiatic  fever,  190 
Sweats,  night-,  in  phthisis,  treatment,  174 
Symptoms,  important,  significance  of,  24 
Synovial  membrane,  298 
S3q3hilis,  113 

alopecia  in,  118 

cerebral,  120 

changes  in  arteries  in,  119 
in  hair  in,  118 
in  nails  in,  118 

clinical  course,  116 

Colles'  law,  120 

contagiousness,  114 

etiology,  115 

heart  affections  in,  119 

lesions  of  mucous  membranes  in,  118 

mucous  patches  in,  118 

neosalvarsan  in,  124 

nephritis  in,  119 

primary  stage,  116 

salvarsan  in,  123 

secondary  stage,  116 

tertiary,  118 

treatment,  121 
Sjqjhilitic  currhosis  of  liver,  409 

tumors  of  brain,  621 
SjHphiloderm,  118 

variola  and,  differentiation,  118 
Syphiloma  of  brain,  620 
Syringomyelia,  569 

treatment,  572 


INDEX 


66=; 


Tabes  dorsalis,  124 

affections  of  bones  in,  129 

of  joints  in,  129 
Argyll-Robertson  sign  in,  126 
cardiac  crises  in,  129 
Charcot's  disease  in,  129 
circulatory  system  in,  129 
clinical  symptoms,  125 
deafness  in,  128 

Frankel's  treatment  of  walking  in,  132 
gastric  crises  in,  128 
intestinal  crises  in,  129 
laryngeal  crises  in,  129 
lightning  pains  in,  125,  127 
loss  of  knee-jerk  in,  126 
morbid  anatomy,  130 
optic  atrophy  in,  128 
relation  to  special  senses  in,  128 
spinal  degeneration  in,  130 
treatment,  131 
trophic  lesions  in,  129 
vesical  crises  in,  128 
visceral  crises  in,  128 
of  brain,  133 
pain  of,  treatment,  38 
Tachycardia  in  Graves'  disease,  475 
paroxysmal,  291 
treatment,  291 
Taenia  echinococcus,  497 
larvo-punctata,  494 
saginata,  494 
solium,  494 
Tapeworm,  494 

treatment,  495 
Teicopsia,  5^0 
Telephone  aphasia,  616 
Temperature  in  phthisis,  176 
Tenth  nerve,  derangements  of,  598 
Terebene  ozone  vapor  in  bronchiectasis,  321 
Tertian  malaria,  211 
Tertiary  sj^ahilis,  118 
Tetanus,  221 
antitoxin,  223 
bacillus,  222 
emprosthotonos  in,  224 
idiopathic,  224 
opisthotonos  in,  224 
pleurosthotonos  in,  224 
risus  sardonicus  in,  224 
symptoms,  224 
treatment,  225 
Tetany,  465 
Texas  cattle  fever,  209 


Thermic  fever,  611 
Thomsen's  disease,  624 
Thoracic  aneurysm,  cough  in,  53 

nerve,  long,  injury  of,  paralysis  after,  573 
Thrill,  cardiac,  272 

Throat,  douching  of,  as  preventive  of  rheu- 
matic fever,  192 

in  scarlet  fever,  91 
Thrombus,  venous,  in  chlorosis,  238 
Thrush,  333 

Thymol  in  hookworm  disease,  502 
Thymus  gland,  diseases  of,  465 
Thyroid  extract  in  cretinism,  472 

in  myxedema,  464 

in  obesity,  462 

scleroderma,  461 
gland,  465,  469 

effect  of  removal,  487 
Thyroidism  in  Graves'  disease,  493 
Tic  douloureux,  590 

pain  of,  35 
Ticks,  505 
Tight  cough,  55 
Tinnitus  aurium,  597 
Tobacco,  use  of,  343 

Tongue,  strawberry,  in  scarlet  fever,  88 
Tonic,  65 
Tonsillitis  as  precursor  of  rheumatic  fever, 

189 
Torticollis,  600 
Toxic  neuralgia,  febrile,  36 

non-febrile,  36 
Trapezius  paralysis,  573 
Tremor,  intention,  in  disseminated  sclerosis, 

558 
Trichina  spiralis,  498 
Trichiniasis,  498 

treatment,  499 
Trichocephalus  dispar,  503 
Trigeminal  neuralgia,  545,  590 
pain  of,  35 
treatment,  591 
Trigeminus  nerve,  diseases,  589  * 

Trophic  lesions  in  tabes,  129 
Trypanosomiasis,  227 

treatment,  229 
Tsetse  fliy,  227 
Tubal  nephritis,  chronic,  423 
Tubercle  bacillus,  168 

role  of,  170 
Tuberculin  in  diagnosis  of  tuberculosis,  169 
Tuberculosis,  167 

bovine,  169 


666 


INDEX 


Tuberculosis,  care  of  skin  in,  173,  174 
caseous  change  from,  170 
diet  in,  172 
fresh  air  in,  171 
immunity  to,  169 
miliary,  168 
of  bones,  183 
of  skin,  182 

treatment,  183 
of  spine,  582 
oily  inunctions  in,  174 
pulmonary,  167.     See  also  Phthisis. 
treatment,  170 

medicinal,  174 
tuberculin  in  diagnosis  of,  169 
varieties  of,  169 
Tuberculous  laryngitis,  179,  313 

treatment,  180,  314 
Ijonphatic  glands,  180 
meningitis,  181 

treatment,  182 

vomiting  in,  63 
ulceration  of  intestine,  363 
Timiors,  626 
benign,  627 
fatty,  462 
hysteric,  462 
malignant,  626 

autositic,  628 

colloid  degeneration  in,  629 

fatty  metamorphosis  in,  629 

hyalin  degeneration  in,  629 

metastasis  of,  628 

origin  and  nature,  629,  630 

radium  in,  638 
of  brain,  620 
of  kidney,  445 
of  nerves,  622 
syphilitic,  of  brain,  621 
Tympanites  in  typhoid  fever,  154 
Tympanum,  595 
Typhoid  carriers,  76,  149 
bacillus  in  gall-bladder,  396 
fever,  146 

alcohol  in,  160 

arteries  in,  151 

Brand  bath  in,  158 

bronchitis  in,  151,  157 

clinical  course,  149 

cold  bath  in,  158 

constipation  in,  150,  154 

delirium  in,  150,  156 

diarrhea  in,  149,  154,  363 


Typhoid  fever,  diet  in,  160 

emaciation  in,  45 

etiology,  147 

headache  in,  149,  150 

heart  in,  151,  152 

hemorrhage  in,  150,  152,  155 

incubation  period,  149 

lobar  pneumonia  in,  151,  156 

nephritis  in,  158 

nervous  sjonptoms,  151 

perforation  in,  150,  152,  156 

peripheral  neuritis  in,  157 

phlebitis  in,  157 

pulse  in,  150 

rash  of,  152 

relapses,  150,  157 

rose-spots  in,  152 

symptoms,  97 

treatment,  153 

general  line  of,  158 

tympanites  in,  154 

ulceration  in,  151,  152 

veins  in,  151 
Typhus  fever,  96 

symptoms,  97 

treatment,  99 

Ulcer,  duodenal,  347 
hunger  pain  in,  351 
symptoms,  351 
gastroduodenal,  347 
chronic,  351 
treatment,  352 
of  rectum,  390 
of  stomach,  347 

as  cause  of  emaciation,  47 
treatment,  352 
vomiting  in,  61 
tuberculous,  of  intestine.  363 
Ulceration  in  typhoid  fever,  151,  152 
Ulcerative  stomatitis,  334 
Ulnar  paralysis,  574 
Ultramicroscopic  micro-organisms,  75 
Unconsciousness  in  epilepsy,  526 
Urea  diabetes,  454 
Uremia,  432 

epileptiform  convulsions  in,  433 
insanity  in,  433 
symptoms,  432 
cerebral,  433 
circulatory,  434 
gastro-intestinal,  434 
treatment,  434 


INDEX 


667 


Uremic  amaurosis,  433 

insanity,  433 
Urethral  stricture  in  gonorrhea,  135 
Urinary  apparatus,  diseases  of,  420 
Urine,  bacteria  in,  445 

black,  445 

brick-dust  deposit  in,  437 

cystin  in,  444 

fat  in,  443 

hemoglobin  in,  247 

indican  in,  442 

morbid  conditions,  442 

phosphates  in,  443 
Uro tropin  in  cyanosis,  248 

in  indicanuria,  443 

in  infections  by  colon  bacillus,  235 

in  pyelitis,  440 

in  trichiniasis,  499 

VACCnS[ATION,  83 

Vaccines,  70 

administration  of,  72 

as  prophylactic  measure,  72 

as  therapeutic  measure,  72 

autogenous,  72 

in  bacteremia,  72 

stock,  72 
Vagus,  paralysis  of,  600 
Valvular  disease,  chronic,  282 

of  heart  as  cause  of  dyspnea,  58 
cough  in,  S3 
Valvulitis,  rheumatic,  273,  274 
Varicose  veins  of  leg,  254 
Variola,  83.    See  also  Small-pox. 
Varioloid,  8^, 
Varix,  aneurysmal,  268 
Vascillation  in  disseminated  sclerosis,  558 
Vasomotor  nerves  of  feet,  20 

relation  of,  to  catching  cold,  18 
susceptibility  of,  to  cold,  20 
Vater,  ampulla  of,  416 
Veins,  enlargement  of,  253-256 

examination  of,  253 

in  typhoid  fever,  151 

varicose,  of  leg,  254 
Venesection  in  acute  nephritis,  423 
Venous  pulsation,  256 

thrombus  in  chlorosis,  238 
Veratrum  viride,  69 
Veronal  cyanosis,  248 
Vertigo,  534 

in  Graves'  disease,  479 

treatment,  536 


Vesical  crises  in  tabes  dorsalis,  128 
Vesicular  stomatitis,  334 
Vestibular  nerve,  595 

vertigo,  535 
Virulence  of  micro-organisms,  76 
Visceral  crises  in  tabes  dorsalis,  128 
Vision,  disturbances  of,  586,  587 
Vocal  resonance  in  pleurisy,  323 
Voice,  scanning,  in  sclerosis,  557 
Vomiting,  61 

center,  61 

in  accidents  to  abdominal  viscus,  62 

in  carcinoma  of  stomach,  62 

in  fever,  63 

in  gastritis,  61 

in  lobar  pneumonia,  140 

in  scarlet  fever,  treatment,  92 

in  tubercular  meningitis,  63 

in  ulcer  of  stomach,  61 

putrid,  treatment,  62 

stercoraceous,  treatment,  62 

Water-hammer  pulse,  285 

Waxy  liver,  414 

Weil's  disease,  394 

Weir's  treatment  of  mucous  colitis,  385 

Wet  feet,  20,  21 

Whip-worm,  503 

White  kidney,  large,  423 

small  contracted,  425 
WTiooping-cough,  107.     See  also  Pertussis. 

wm,  513 

WilHs,  circle  of,  603 
Wirsimg's  duct,  416 
Woolsorters'  disease,  166 
Word-blindness,  614,  615,  617 
Word-deafness,  596,  614 
Worms,  intestinal,  494 

as  cause  of  cough, 54 
Wrist-drop  in  lead-poisoning,  517 
Writing  center,  614 
Wry-neck,  600 

Xanthopsia,  500 
Z-rays  in  Hodgkin's  disease,  296 
in  leukemia,  245 

Yellow  atrophy,  acute,  of  liver,  413 

fever,  218—221 

vision,  500 
Yellow-tail  moth,  506 

Zoolak,  345 


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pansion of  our  business  both  at  home  and  abroad.  In  1905  we  advertised  in 
10  journals  ;  in  1906  and  1907,  in  11  journals;  in  I908,  in  13  journals;  in  1909, 
in  16  journals;  in  1910,  in  17  journals;  in  191 1,  in  18  journals;  in  1912,  in  20 
journals  ;  and  in  19 13,  in  26  journals.  Our  announcements  now  have  an  annual 
circulation  of  over  5,000,000,  or  nearly  100,000  every  week  in  the  year. 

A  Complete  Catalogue  of  Our  Publications  will  be  Sent  Upon  Request 


SAUNDERS'    BOOKS   ON 


De  Lee*s 
Obstetrics 


Principles  asad  Practice  of  Obstetrics.  By  Joseph  B.  De  Lee, 
M.  D.,  Professor  of  Obstetrics  in  the  Northwestern  University  Medical 
School,  Chicago.  Large  octavo  of  1060  pages,  with  913  illustrations, 
150  in  colors.     Cloth,  ^8.00  net;  Half  Morocco,  $<^.SO  net 

THREE  PRINTINGS  IN  TEN  MONTHS 

Th©  Most  Swperb  Book  on  Obstetrics  Ever  Published 

You  will  pronounce  this  new  book  by  Dr.  De  Lee  the  most  elaborate,  the 
most  superbly  illustrated  work  on  Obstetrics  you  have  ever  seen.  Especially  will 
you  value  the  gij  illustrations,  practically  all  original,  and  the  best  work  of  lead- 
ing medical  artists.  Some  1 50  of  these  illustrations  are  in  colors.  Such  a  mag- 
nificent collection  of  obstetric  pictures — and  with  really  practical  value — has  never 
before  appeared  in  one  book. 

You  will  find  the  text  extremely  practical  throughout.  Dr.  De  Lee's  aim  being  to 
produce  a  book  that  would  meet  the  needs  of  the  general  practitioner  in  every  par- 
ticular. For  this  reason  diagnosis  is  featured,  and  the  relations  of  obstetric  con- 
ditions and  accidents  to  general  medicine,  surgery,  and  the  specialties  brought  into 
prominence. 

Regarding  treatment :  You  get  here  the  very  latest  advances  in  this  field,  and  you 
can  rest  assured  every  method  of  treatment,  every  step  in  operative  technic,  is  just 
right.  Dr.  De  Lee's  twenty -one  years'  experience  as  a  teacher  and  obstetrician 
guarantees  this. 

Worthy  of  your  particular  attention  are  the  descriptive  legends  under  the  illus- 
trations. These  are  unusually  full,  and  by  studying  the  pictures  serially  with  their 
detailed  legends,  you  are  better  able  to  follow  the  operations  than  by  referring  to 
the  pictures  from  a  distant  text — the  usual  method. 

Dfc  M.  A.  Hann&,  University  Medir.al  College,  Kansas  City 

"  I  am  trank  in  stating  that  I  pri7,e  it  more  highly  than  any  other  volume  in  my  obstetric 
library,  which  consists  of  practically  all  the  recent  boolis  on  that  subject." 

Dr.  Clark  E.  Day,  Indianapolis,  Ind 

"  Dr.  DeLee's  work  is  by  far  the  greatest  on  Obstetrics  published  to-day  for  the  general 
practitioner.  It  will  meet  what  is  expected  of  it  in  a  more  concise  and  comprehensive  way 
than  any  other  book  he  could  buy.'' 

Dr.  George  L.  Brodhead,  A/ew  York  Post- Graduate  Medical  School 

"  The  name  of  the  author  is  in  itself  a  sufficient  guarantee  of  the  merit  of  the  book,  and  I 
congratulate  him,  as  well  as  you,  on  the  superb  work  just  published." 


G  YNECOL OGY  AND   O BS TE TR ICS. 


Norris* 
Gonorrhea  in  Women 

Gonorrhea  in  Women.  By  Charles  C.  Norris,  M.  D.,  Instructor 
in  Gynecology,  University  of  Pennsylvania.  With  an  Introduction  by 
John  G.  Clark,  M.  D.,  Professor  of  G)'necology,  University  of  Penn- 
sylvania.    Large  octavo  of  520  pages,  illustrated.  Cloth,  ;SS6.oo  net. 

A    CLASSIC 

Dr.  Norris  here  presents  a  work  that  is  destined  to  take  high  place  among 
publications  on  this  subject.  He  has  done  his  work  thoroughly.  He  has  searched 
the  important  literature  very  carefully,  over  2300  references  being  utilized.  This, 
coupled  with  Dr.  Norris'  large  experience,  gives  his  book  the  stamp  of  authority. 
The  chapter  on  serum  and  vaccine  therapy  and  organotherapy  is  particularly 
valuable  because  it  expresses  the  newest  advances.  Every  phase  of  the  subject 
is  considered:  History,  bacteriology,  pathology,  sociology,  prophylaxis,  treatment 
(operative  and  medicinal),  gonorrhea  during  pregnancy,  parturition  and  puer- 
perium,  diffuse  gonorrheal  pertitonitis,  and  all  other  phases.  Furthur,  Dr.  Norris 
also  considers  the  rare  varieties  of  gonorrhea  occurring  in  men,  women,  and 
children.      The  text  is  illustrated. 

American  Text-Book  qf  Gynecology 

Second    Revised   Edition 
American  Text=Book  of  Gynecology.     Edited   by  J.    M.    Baldy, 
M.  D.     Imperial  octavo  of  718  pages,  with  341   text-illustrations  and 
38  plates.     Cloth,  ;$6.oo  net. 

American  Text-Book  qf  Obstetrics 

Second    Revised    Edition 
The  American  Text=Book  of  Obstetrics.     In  two  volumes.    Edited 
by  Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L.  Dickinson,  M.  D. 
Two  octavos  of  about  600  pages  each ;  nearly  900  illustrations,  includ- 
ing 49  colored  and  half-tone  plates.      Per  volume  :  Cloth,  ;^3.5o  net. 

"  As  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  practi- 
tioner, we  commend  it  because  we  believe  there  is  no  better." — American  Journal  of  the 
Medical  Sciences. 


SAUNDERS'   BOOKS   ON 


Ashton's 
Practice  of  Gynecology 


The  Practice  of  Gynecology.     By  W.  Easterly  Ash  ton,  M.  D., 

LL.D.,  Professor  of  Gynecology  in  the  Medico-Chirurgical  College, 
Philadelphia.  Handsome  octavo  volume  of  i  lOO  pages,  containing  1058 
original  line  drawings.     Cloth,  $6.^0  net;   Half  Morocco,  |8.00  net. 

NEW  (5th)  EDITION 

The  continued  success  of  Dr.  Ashton's  work  is  not  surprising  to  any  one 
knowing  the  book.  The  author  takes  up  each  procedure  necessary  to  gynecologic 
step  by  step,  the  student  being  led  from  one  step  to  another,  just  as  in  studying 
any  non-medical  subject,  the  minutest  detail  being  explained  in  language  that 
cannot  fail  to  be  understood  even  at  first  reading.  Nothing  is  left  to  be  taken  for 
granted,  the  author  not  only  telling  his  readers  in  every  instance  what  should  be 
done,  but  also  precisely  how  to  do  it.  A  distinctly  original  feature  of  the  book  is 
the  illustrations,  numbering  1058  line  drawings  made  especially  under  the  author's 
personal  supervision  from  actual  apparatus,  living  models,  and  dissections  on  the 
cadaver. 

From  its  first  appearance  Dr.  Ashton's  book  set  a  standard  in  practical 
medical  books  ;  that  he  has  produced  a  work  of  unusual  value  to  the  medical 
practitioner  is  shown  by  the  demand  for  new  editions.  Indeed,  the  book  is  a 
rich  store-house  of  practical  information,  presented  in  such  a  way  that  the  work 
cannot  fail  to  be  of  daily  service  to  the  practitioner. 

Howard  A.  Kelly.  M.  D. 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University . 

"  It  is  different  from  anything  that  has  as  yet  appeared.  The  illustrations  are  particularly 
clear  and  satisfactory.  One  specially  good  feature  is  the  pains  with  which  you  describe  sc 
many  details  so  often  left  to  the  imagination." 

Charles  B.  Penrose,  M.  D. 

Formerly  Professor  of  Gynecology  in  the  University  of  Pennsylvania 

"  I  know  of  no  book  that  goes  so  thoroughly  and  satisfactorily  into  all  the  details  of  every- 
thing connected  with  the  subject.     In  this  respect  your  book  differs  from  the  others." 

George  M.  Edebohls.  M.  D. 

Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Medical  School 
"  A  text-book  most  admirably  adapted  to  teach  gynecology  to  those  who  must  get  theil 
knowledge,  even  to  the  minutest  and  most  elementary  details,  from  books." 


GYNECOLOGY  AND    onS'IKTRICS 


Bandler's 
Medical    Gynecology 


Medical  Gynecology.  By  S.  Wyllls  Bandler,  M.  D.,  Adjunct 
Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Medical 
School  and  Hospital.  Octavo  of  790  pages,  with  150  original  illus- 
trations.    Cloth,  ^5.00  net;  Half  Morocco,  ^6.50  net. 

NEW  (3d)  EDITION— 60  PAGES  ON  INTERNAL  SECRETIONS 

This  new  work  by  Dr.  Bandler  is  just  the  book  that  the  physician  engaged  in 
general  practice  has  long  needed.  It  is  truly  the  practitioner  s  gyticcology — planned 
for  him,  written  for  him,  and  illustrated  for  him.  There  are  many  gynecologic 
conditions  that  do  not  call  for  operative  treatment  ;  yet,  because  of  lack  of  that 
special  knowledge  required  for  their  diagnosis  and  treatment,  the  general  practi- 
tioner has  been  unable  to  treat  them  intelligently.  This  work  not  only  deals 
with  those  conditions  amenable  to  non-operative  treatment,  but  it  also  tells  how  to 
recognize  those  diseases  demanding  operative  treatment. 

American  Journal  of  Obstetrics 

"  He  has  shown  good  judgment  in  the  selection  of  his  data.  He  has  placed  most  emphasis 
on  diagnostic  and  therapeutic  aspects.  He  has  presented  his  facts  in  a  manner  to  be  readily 
grasped  by  the  general  practitioner." 


handler's  Vaginal   Celiotomy 

Vaginal  Celiotomy.  By  S.  Wyllis  Bandler,  M.  D.,  New  York 
Post-Graduate  Medical  School  and  Hospital.  Octavo  of  450  pages,  with 
148  original  illustrations.     Cloth,  $5.00  net;  Half  Morocco,  $6.50  net. 

SUPERB  ILLUSTRATIONS 

The  vaginal  route,  because  of  its  simplicity,  ease  of  execution,  absence  of 
shock,  more  certain  results,  and  the  opportunity  for  conservative  measures,  con- 
stitutes a  field  which  should  appeal  to  all  surgeons,  gynecologists,  and  obstetricians. 
Posterior  vaginal  celiotomy  is  of  great  importance  in  the  removal  of  small  tubal 
and  ovarian  tumors  and  cysts,  and  is  an  important  step  in  the  performance  of 
vaginal  myomectomy,  hysterectomy,  and  hysteromyomectomy.  Anterior  vaginal 
celiotomy  with  thorough  separation  of  the  bladder  is  the  only  certain  method 
of  correcting  cystocele. 

The  Lancet,  London 

"  Dr.  Bandler  has  done  good  service  in  writing  this  book,  which  gives  a  very  clear  descrip- 
tion of  all  the  operations  which  may  be  undertaken  through  the  vagina.  He  makes  out  a 
Strong  case  for  these  operations." 


SAUNDERS'    BOOKS   ON 


Kelly  and   Noble*s 

Gynecology 

and  Abdominal  Surgery 


Gynecology  and  Abdominal  Surgery.  Edited  by  Howard  A. 
Kelly,  M.  D.,  Professor  of  Gynecology  in  Johns  Hopkins  University  ; 
and  Charles  P.  Noble,  M.  D.,  formerly  Clinical  Professor  of  Gyne- 
cology in  the  Woman's  Medical  College,  Philadelphia.  Two  imperial 
octavo  volumes  of  950  pages  each,  containing  880  illustrations,  some  in 
.colors.     Per  volume:   Cloth,  $8.00  net ;   Half  Morocco,  ;^9. 50  net. 

TRANSLATED  INTO  SPANISH 
WITH   880   ILLUSTRATIONS   BY  HERMANN  BECKER   AND   MAX   BRODEL 

In  view  of  the  intimate  association  of  gynecology  with  abdominal  surgery  the 
editors  have  combined  these  two  important  subjects  in  one  work.  For  this  reason 
the  work  will  be  doubly  valuable,  for  not  only  the  gynecologist  and  general  prac- 
titioner will  find  it  an  exhaustive  treatise,  but  the  surgeon  also  will  find  here  the 
latest  technic  of  the  various  abdominal  operations.  It  possesses  a  number  of 
valuable  features  not  to  be  found  in  any  other  publication  covering  the  same  fields. 
It  contains  a  chapter  upon  the  bacteriology  and  one  upon  the  pathology  of  gyne- 
cology, dealing  fully  with  the  scientific  basis  of  gynecology.  In  no  other  work 
can  this  information,  prepared  by  specialists,  be  found  as  separate  chapters. 
There  is  a  large  chapter  devoted  entirely  to  medical  gynecology  written  especially 
for  the  physician  engaged  in  general  practice.  Heretofore  the  general  practitioner 
was  compelled  to  search  through  an  entire  work  in  order  to  obtain  the  information 
desired.  Abdojnmal  surgery  proper,  as  distinct  from  gynecology,  is  fully  treated, 
embracing  operations  upon  the  stomach,  upon  the  intestines,  upon  the  liver  and 
bile-ducts,  upon  the  pancreas  and  spleen,  upon  the  kidneys,  ureter,  bladder,  and 
the  iperitoneum.  The  illustrations  are  truly  magnificent,  being  the  work  of  Mr. 
Her))ia7in  Becker  and  Mr.  Max  Br'ddel. 

Americeui  Journal  of  the  Medical  Sciences 

"  It  is  needless  to  say  that  the  work  has  been  thoroughly  done  :  the  names  of  the  authors 
and  editors  would  guarantee  this ;  but  much  may  be  said  in  praise  of  the  method  of  presen- 
tation, and  attention  may  be  called  to  the  inclusion  of  matter  uot  to  be  found  elsewhere." 


G  YNECOLOG  Y  AND   OBSTETRICS 


Webster's 
Text-Book  qf  Obstetrics 

A  Text-Book  of  Obstetrics.  By  J.  Clarence  Webster,  M.  D. 
(Edin.),  F.  R.  C.  p.  E.,  Professor  of  Obstetrics  and  Gynecology  in  Rush 
Medical  College,  in  afifiliatioa  with  the  University  of  Chicago.  Octavo 
volume  of  J^y  pages,  illustrated.  Cloth,  ^5.00  net;  Half  Morocco, 
^6.50  net. 

BEAUTIFULLY     ILLUSTRATED 

In  this  work  the  anatomic  changes  accompanying  pregnancy,  labor,  and  the 
puerperium  are  described  more  fully  and  lucidly  than  in  any  other  text-book  on 
the  subject.  The  exposition  of  these  sections  is  based  mainly  upon  studies  of 
frozen  specimens.  Unusual  consideration  is  given  to  embryologic  and  physiologic 
data  of  importance  in  their  relation  to  obstetrics. 

Buffalo  Medical  Journal 

"  As  a  practical  text-book  on  obstetrics  for  both  student  and  practitioner,  there  is  left  very 
little  to  be  desired,  it  being  as  near  perfection  as  any  compact  work  that  has  been  published." 


Webster's 
Diseases   of  Women 

A  Text=Book  of  Diseases  of  Women.  By  J.  Clarence  Webster, 
M.  D.  (Edin.),  F.  R.  C.  P.  E.,  Professor  of  Gynecology  and  Obstetrics 
in  Rush  Medical  College.  Octavo  of  712  pages,  with  372  text-illustra- 
tions and  10  colored  plates.     Cloth,  ^$7.00  net ;  Half  Morocco,  ^8.50  net. 

Dr.  Webster  has  written  this  work  especially  for  the  general  practitioner,  dis- 
cussing the  clinical  features  of  the  subject  in  their  widest  relations  to  general 
practice  rather  than  from  the  standpoint  of  specialism.  The  magnificent  illus- 
trations, three  hundred  and  seventy-two  in  number,  are  nearly  all  original. 

Howard  A.  Kelly.  M.  D. 

Professor  of  Gynecologic  Surgery,  fohns  Hopkins  University. 

"It  is  undoubtedly  one  of  the  best  works  which  has  been  put  on  the  market  within  recent 
years,  showing  from  start  to  finish  Dr.  Webster's  well-known  thoroughness.  The  illustrations 
are  also  of  the  highest  order." 


SAUNDERS'   BOOKS   ON 


Hirst's 
Text-Book  of  Obstetrics 

The  New  (7th)  Edition 


A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome 
octavo  of  1013  pages,  with  895  illustrations,  53  of  them  in  colors. 
Cloth,  ^5.00  net ;  Half  Morocco,  $6.50  net. 

INCLUDING  RELATED  GYNECOLOGIC  OPERATIONS 

Immediately  on  its  publication  this  work  took  its  place  as  the  leading  text-book 
on  the  subject.  Both  in  this  country  and  in  England  it  is  recognized  as  the  most 
satisfactorily  written  and  clearly  illustrated  work  on  obstetrics  in  the  language. 
The  illustrations  form  one  of  the  features  of  the  book.  They  are  numerous  and 
the  most  of  them  are  original.  In  this  edition  the  book  has  been  thoroughly  revised. 
Recognizing  the  inseparable  relation  between  obstetrics  and  certain  gynecologic 
conditions,  the  author  has  included  all  the  gynecologic  operations  for  complica- 
tions and  consequences  of  childbirth,  together  with  a  brief  account  of  the  diagnosis 
and  treatment  of  all  the  pathologic  phenomena  peculiar  to  women. 


OPINIONS  OF  THE   MEDICAL  PRESS 


British  Medical  Journal 

"  The  popularity  of  American  text-books  in  this  country  is  one  of  the  features  of  recent 
years.  The  popularity  is  probably  chiefly  due  to  the  great  superiority  of  their  illustrations 
over  those  of  the  English  text-books.  The  illustrations  in  Dr.  Hirst's  volume  are  far  more 
numerous  and  far  better  executed,  and  therefore  more  instructive,  than  those  commonly 
found  in  the  works  of  writers  on  obstetrics  in  our  own  country." 

Bulletin  of  Johns  Hopkins  Hospital 

"The  work  is  an  admirable  one  in  every  sense  of  the  word,  concisely  but  comprehensively 
written." 

The  Medical  Record,  New  York 

"The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the  first 
time.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never  necessary 
to  re-read  a  sentence  in  order  to  grasp  the  meaning.  As  a  true  model  of  what  a  modern  text- 
book on  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's  book  is  without  a 
rival." 


DISEASES   OF    WOMEN. 


HirstV 

Diseases  of  Women 


A  Text=Book  of  Diseases  of  Women.  By  Barton  Cooke  Hirst, 
M.  D.,  Professor  of  Obstetrics,  University  of  Pennsylvania  ;  Gynecolo- 
gist to  the  Howard,  the  Orthopedic,  and  the  Philadelphia  Hospitals, 
Octavo  of  745  pages,  with  701  original  illustrations,  many  in  colors. 
Cloth,  ^5.00  net;  Half  Morocco,  ^6.50  net. 

THE    NEW   (2d)    EDITION 
WITH    701    ORIGINAL    ILLUSTRATIONS 

The  new  edition  of  this  work  has  just  been  issued  after  a  careful  revision. 
As  diagnosis  and  treatment  are  of  the  greatest  importance  in  considering  diseases 
of  women,  particular  attention  has  been  devoted  to  these  divisions.  To  this  end, 
also,  the  work  has  been  magnificently  illuminated  with  701  illustrations,  for  the 
most  part  original  photographs  and  water-colors  of  actual  clinical  cases  accumu- 
lated during  the  past  fifteen  years.  The  palliative  treatment,  as  well  as  the 
radical  operative,  is  fully  described,  enabling  the  general  practitioner  to  treat 
many  of  his  own  patients  i.ilhout  referring  them  to  a  specialist.  An  entire  sec- 
tion is  devoted  to  r.  full  description  of  all  modern  gynecologic  operations,  illumi- 
nated and  elucidated  by  numerous  photographs.  The  author's  extensive  ex- 
perience renders  .nis  work  of  unusual  value. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  Record,  New  York 

"  Its  merits  can  be  appreciated  only  by  a  careful  perusal.  .  .  .  Nearly  one  hundred  pages 
are  devoted  to  technic,  this  chapter  being  in  some  respects  superior  to  the  descriptions  in 
many  other  text-  boks." 

Boston  Medical  and  Surgical  Journal 

"The  author  has  given  special  attention  to  diagnosis  and  treatment  throughout  the  book, 
and  has  produced  a  practical  treatise  which  should  be  of  the  greatest  value  to  the  student,  the 
general  practitioner,  and  the  specialist." 

Medical  News,  New  York 

"Office  treatment  is  given  a  due  amount  of  consideration,  so  that  the  work  will  be  as 
useful  to  the  non-operator  as  to  the  specialist." 


SAUNDERS'    BOOKS   ON 


GET  i^ •  THE  NEW 

THE  BEST  /\  lU  ©  r  I  C  &  ri  STANDARD 

Illustrated   Dictionary 

New  (7th)  Edition— 5000  Sold  in  Two  Months 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches;  with  over  loonew  and  elaborate  tables  and  many  handsome 
illustrations.  By  W.  A.  Newman  Borland,  M.D.,  Editor  of  "  The 
American  Pocket  Medical  Dictionary."  Large  octavo,  1107  pages, 
bound  in  full  flexible  leather.  Price,  ^4.50  net;  with  thumb  index, 
$5.00  net. 

IT  DEFINES  ALL  THE  NEW  WORDS— MANY  NEW  FEATURES 

The  American  Illustrated  Medical  Dictionary  defines  hundreds  of  the  newest 
terms  not  defined  in  any  other  dictionary — bar  none.  These  new  terms  are  live, 
active  words,  taken  right  from  modern  medical  literature. 

It  gives  the  capitalization  and  pronunciation  of  all  words.  It  makes  a  feature 
of  the  derivation  or  etymology  of  the  words.  In  some  dictionaries  the  etymology 
occupies  only  a  secondary  place,  in  many  cases  no  derivation  being  given  at  all. 

In  the  "American  Illustrated"  practically  every  word  is  given  its  derivation. 

Every  word  has  a  separate  paragraph,  thus  making  it  easy  to  find  a  word 
quickly. 

The  tables  of  arteries,  muscles,  nerves,  veins,  etc.,  are  of  the  greatest  help 
in  assembling  anatomic  facts.  In  them  are  classified  for  quick  study  all  the 
necessary  information  about  the  various  structures. 

Every  word  is  given  its  definition — a  definition  that  defines  in  the  fewest  pos- 
sible words.  In  some  dictionaries  hundreds  of  words  are  not  defined  at  all,  refer- 
ring the  reader  to  some  other  source  for  the  information  he  wants  at  once. 

Howard  A.  Kelly,  M.  \),y  Johns  Hopkins  University,  Baltimore 

"  The  American  Illustrated  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such 
convenient  size.     No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren,  M.  D.,  LL.D.,  F.R.C.S.  (Hon.),  Harvard  Medical  School 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.  It  is  very  complete  and  of 
convenient  size  to  handle  comfortably.     I  use  it  in  preference  to  any  other." 


G  YN ECO  LOG  Y  A  ND    OBS  TE  TRfCS 


Penrose's 
Diseases  of  Women 

Sixth    Revised    Edition 


A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose, 
M.  D.,  Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of 
Pennsylvania ;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Oc- 
tavo volume  of  550  pages,  with   225  fine  original  illustrations.      Cloth, 

^3.75   net. 

ILLUSTRATED 

Regularly  every  year  a  new  edition  of  this  excellent  text-book  is  called  for, 
and  it  appears  to  be  in  as  great  favor  with  physicians  as  with  students.  Indeed, 
this  book  has  taken  its  place  as  the  ideal  work  for  the  general  practitioner.  The 
author  presents  the  best  teaching  of  modern  gynecology,  untrammeled  by  anti- 
quated ideas  and  methods.  In  every  case  the  most  modern  and  progressive 
technique  is  adopted  and  made  clear  by  excellent  illustrations, 

Howard  A.  Kelly,  M.D.. 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University,  Baltimore. 

"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women  '  received.  I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." 


Davis'  Operative  Obstetrics 

operative  Obstetrics.  By  Edward  P.  Davis,  M.D.,  Professor  of 
Obstetrics  at  Jefferson  Medical  College,  Philadelphia.  Octavo  of  483 
pages,  with  264  illustrations.     Cloth,  $5.50  net;  Half  Morocco,  ^7.00  net. 

INCLUDING  SURGERY  OF  NEWBORN 

Dr.  Davis*  new  work  is  a  most  practical  one,  and  no  expense  has  been  spared 
to  make  it  the  handsomest  work  on  the  subject  as  well.  Every  step  in  every 
operation  is  described  minutely,  and  the  technic  shown  by  beautiful  new  illustra- 
tions.     Dr.  Davis'  name  is  sufficient  guarantee  for  something  above  the  mediocre. 


"  SAUNDERS'    BOOKS   ON 

Dorland's 
Modern   Obstetrics 


Modern  Obstetrics:  General  and  Operative.     By  W.  A.  Newman 

Borland,  A.  M.,  M.  D.,  Professor  of  Obstetrics  at  Loyola  University, 
Chicago,  Illinois.  Handsome  octavo  volume  of  797  pages,  with  201 
illustrations.     Cloth,  ^4.00  net. 

Second  Edition,  Revised  and  Greatly  Enlarged 

In  this  edition  the  book  has  been  entirely  rewritten  and  very  greatly  enlarged. 

Among  the  new  subjects  introduced  are  the  surgical  treatment  of  puerperal  sepsis, 

infant  mortality,  placental   transmission  of  diseases,  serum-therapy  of  puerperal 

sepsis,  etc.      By  new  illustrations  the  text  has  been  elucidated,  and  the  subject  pre- 

'  sented  in  a  most  instructive  and  acceptable  form. 

Journal  of  the  American  Medical  Association 

"  This  work  deserves  commendation,  and  that  it  has  received  what  it  deserves  at  the  hands 
of  the  profession  is  attested  by  the  fact  that  a  second  edition  is  called  for  within  such  a  short 
time.     Especially  deserving  of  praise  is  the  chapter  on  puerperal  sepsis." 

Davis'  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Obstetrics  in  the  Jefferson  Medical  College  and 
Philadelphia  Polyclinic ;  Obstetrician  and  Gynecologist,  Philadelphia 
Hospital.      i2mo  of  480  pages,  illustrated.     Buckram,  $1.7^  ^^st. 

NEW  (4th)  EDITION 
Obstetric  nursing  demands  some  knowledge  of  natural  pregnancy,  and  gyne- 
cologic nursing,  really  a  branch  of  surgical  nursing,  requires  special  instruction 
and  training.  This  volume  presents  this  information  in  the  most  convenient 
form.  This  third  edition  has  been  very  carefully  revised  throughout,  bringing  the 
subject  down  to  date. 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 


GYNECOLOGY  AND    OBSTET/UCS. 


Kelly  and  Cullen*s 
Myomata   of  the  Uterus 


Myomataof  the  Uterus.  By  Howard  A.  Kellv,  M.  D.,  Professor 
of  Gynecologic  Surgery  at  Johns  Hopkins  University;  and  Thomas  S. 
CuLLEN,  M.  B.,  Associate  in  Gynecology  at  Johns  Hopkins  University. 
Large  octavo  of  about  700  pages,  with  388  original  illustrations,  by 
August  Horn  and  Hermann  Becker.  Cloth,  1^7.50  net ;  Half  Morocco, 
;^9.oo  net. 

ILLUSTRATED     BY     AUGUST     HORN     AND     HERMANN     BECKER 

This  nionumental  work,  the  fruit  of  over  ten  years  of  untiring  labors,  will 
remain  for  many  years  the  last  word  upon  the  subject.  Written  by  those  men 
who  have  brought,  step  by  step,  the  operative  treatment  of  uterine  myoma  to 
such  perfection  that  the  mortality  is  now  less  than  one  per  cent.,  it  stands  out  as 
the  record  of  greatest  achievement  of  recent  times. 

Surgery,  Gynecology,  and  Obstetrics 

"It  must  be  considered  as  the  most  comprehensive  work  of  the  kind  yet  published.  It 
will  always  be  a  mine  of  wealth  to  future  students." 


Cullen's  Adenomyoma  of  the  Uterus 

Adenomyoma  of  the  Uterus.  By  Thomas  S.  Cullen,  M.B.  Octavo  of  275 
pages,  with  original  illustrations  by  Hermann  Becker  and  August  Horn.  Cloth, 
^5.00  net ;  Half  Morocco,  ^6.50  net. 

"  A  good  example  of  how  such  a  monograph  should  be  written.  It  is  an  excellent 
work,  worthy  of  the  high  reputation  of  the  author  and  of  the  school  from  which  it 
emanates." — The  Lancet,  London. 

Cullen's  Cancer  of  the  Uterus 

Cancer  of  the  Uterus.  By  Thomas  S.  Cullen,  M.  B.  Large  octavo  of  693 
pages,  with  over  300  colored  and  half-tone  text-cuts  and  eleven  lithographs.  Cloth, 
^7.50  net  ;   Half  Morocco,  ^8.50  net. 

"  Dr.  Cullen's  book  is  the  standard  work  on  the  greatest  problem  which  faces  the 
surgical  world  to-day.  Any  one  who  desires  to  attack  this  great  problem  must  have 
this  book." — Howard  A.  Kelly,  M.  D.,  Jokits  Hopkins  University. 


14  SAUNDERS'    BOOKS   ON 


Schaffer  and  Edi(ar*s  Labor  and  Operative  Obstetrics 

Atlas  and    Epitome   of    Labor    and    Operative    Obstetrics.      By    Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School,  New  York.  With  14  lithographic  plates  in  colors,  139  text- 
cuts,  and  III  pages  of  text.     Cloth,  ^2.00  net.     In  Saunders"  Hand-AUases. 


Schaffer     and     Edgar's     Obstetric     Diagnosis     and 
Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and   Treatment.     By  Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
M.  D. ,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School,  New  York.  With  122  colored  figures  on  56  plates,  38  text- 
cuts,  and  315  pages  of  text.      Cloth,   $3.00  net.      Saunders   Hand-Atlases. 


Schaffer  and  Norris*  Gynecology 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of  Heidel- 
berg. Edited,  with  additions,  by  Richard  C.  Norris,  A.  M.,  M.  D., 
Gynecologist  to  Methodist  Episcopal  and  Philadelphia  Hospitals.  With  207 
colored  figures  on  90  plates,  65  text-cuts,  and  308  pages  of  text.  Cloth, 
^3.50  net.      In  Saunders'  Hand-Atlas  Series. 


Galbraith's  Four  Epochs  of  Woman's  Life 

New  (2d)  Edition 

The  Four  Epochs  of  Woman's  Life :  A  Study  in  Hygiene.  By  Anna 
M.  Galbraith,  M.  D.,  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
With  an  Introductory  Note  by  John  H.  Musser,  M.  D.,  University  of 
Pennsylvania.      i2mo  of  247  pages.     Cloth,  $1.50  net. 

Birmingham  Medical  Review,  England 

"  We  do  not,  as  a  rule,  care  for  medical  books  written  for  the  instruction  of  the  public. 
But  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is,  in  the  main,  wise  and 
wholesome." 


Gairrigues'  Diseases  of  Women  Third  Edition 

A  Text=Book  of  Diseases  of  Women.  By  Henry  J.  Garrigues,  M.  D., 
Gynecologist  to  St.  Mark's  Hospital,  New  York  City.  Octavo  of  756  pages, 
illustrated.      Cloth,  $4. 50  net  ;   Half  Morocco,  $6.00  net. 


GVNECOLO(;V  AND    OBSTETRICS.  15 

Schaffer  and  Webster's 
Operative  Gynecology 


Atlas  and  Epitome  of  Operative  Gynecology.  By  Dr.  O.  Schaf- 
fer, of  Heidelberg.  Edited,  with  additions,  by  J.  Clarence  Webster, 
M.D.  (Edin.),  F.R.C.P.E.,  Professor  of  Obstetrics  and  Gynecology  in 
Rush  Medical  College,  in  affiliation  with  the  University  of  Chicago. 
42  colored  lithographic  plates,  many  text-cuts,  a  number  in  colors,  and 
138  pages  of  text.     In  Saunders'  Hand- Atlas  Series.    Cloth,  $3.00  net. 


Much  patient  endeavor  has  been  expended  by  the  author,  the  artist,  and  the 
lithographer  in  the  preparation  of  the  plates  of  this  atlas.  They  are  based  on 
hundreds  of  photographs  taken  from  nature,  and  illustrate  most  faithfully  the 
various  surgical  situations.  Dr.  Schaffer  has  made  a  specialty  of  demonstrating 
by  illustrations. 

Medical  Record,  New  York 

"  The  volume  should  prove  most  helpful  to  students  and  others  in  grasping  details  usually 
to  be  acquired  only  in  the  amphitheater  itself." 

De  Lee's 
Obstetrics  for  Nurses 

Obstetrics  for  Nurses.  By  Joseph  B.  De  Lee,  M.D.,  Professor  of 
Obstetrics  in  the  Northwestern  University  Medical  School ;  Lecturer 
in  the  Nurses'  Training  Schools  of  Mercy,  Wesley,  Provident,  Cook 
County,  and  Chicago  Lying-in  Hospitals.  i2mo  volume  of  508  pages, 
fully  illustrated.  '■      Cloth,  ^2.50  net. 

THE  NEW  (4th)  EDITION 

"While  Dr.  De  Lee  has  written  his  work  especially  for  nurses,  yet  the  prac- 
titioner will  find  it  useful  and  instructive,  since  the  duties  of  a  nurse  often  devolve 
upon  him  in  the  early  years  of  his  practice.  The  illustrations  are  nearly  all 
original,  and  represent  photographs  taken  from  actual  scenes.  The  text  is  the 
result  of  the  author's  many  years'  experience  in  lecturing  to  the  nurses  of  five 
different  training  schcols. 

J.  Clifton  Edgar,  M.  D., 

Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University ,  New  York. 
"  It  is  far  and  away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  in 
recommending  it  to  my  nurses,  and  students  as  well." 


SAUNDERS'  BOOKS  ON  GYNECOLOGY  AND   OBSTETRICS. 

American  Pocket  Dictionary  New  (8th)  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Borland,  A.  M.,  M.  D.  677  pages.  ;^i.oo  net;  with 
patent  thumb  index,  ^1.25  net. 

James  W.  Holland,  M.  D., 

Professor   of  Medical   Chemistry    and    Toxicology    at  the  Jefferson    Medical    College^ 

Philadelphia. 
"  I  am  struck  at  once  with  admiration  at  the   compact  size  and  attractive   exterior.     J 
can  recommend  it  to  our  students  without  reserve." 

Cragin's  Gynecoloj»y.  New (7th)  Edition 

Essentials  of  Gynecology.  By  Edwin  B.  Cragin,  M.  D., 
Professor  of  Obstetrics,  College  of  Physicians  and  Surgeons,  New 
York.  Crown  octavo,  232  pages,  59  illustrations.  Cloth,  ^i.oo 
net.     In  Saunders'   Question- Cornpend  Series. 

The  Medical  Record,  New  York 

"  A  handy  volume  and  a  distinct  improvement  ol  students'  compends  in  general. 
No  author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the 
student's  needs  so  thoroughly  as  Dr.  Cragin  has  done." 

Ashton'S    Obstetrics.  New  (7th)  Edition 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D., 
Professor  of  Gynecology  in  the  Medico-Chirurgical  College,  Phila- 
delphia. Revised  by  John  A.  McGlinn,  M.  D.,  Assistant  Professor 
of  Obstetrics  in  the  Medico-Chirurgical  College  of  Philadelphia. 
i2moof  287pages,  109  illustrations.  Cloth,  ^i. 00  net.  In  Saunders^ 
Question-  Cornpend  Series. 

Southern  Practitioner 

"An  excellent  httle  volume  containing  correct  and  practical  knowledge.  An  admir- 
able cornpend,  and  the  best  condensation  we  have  seen." 

Barton  and  Wells'  Medical  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred 
M.  Barton,  M.  D.,  Assistant  to  Professor  of  Materia  Medica  and 
Therapeutics,  Georgetown  University,  Washington,  D.  C. ;  and 
Walter  A.  Wells,  M.  D.,  Demonstrator  of  Laryngology,  George- 
town University,  Washington,  D.  C.  i2mo  of  534  pages.  Flex- 
ible leather,  1^2.50  net;  with  thumb  index,  ^3.00  net. 

Macfarlane's   Gynecology  for  Nurses  second  Edition 

A  Reference  Hand-Book  of  Gynecology  for  Nurses.  By  Cath- 
arine Macfarlane,  M.  D.,  Gynecologist  to  the  Woman's  Hospital  of 
Philadelphia.  .32mo  of  150  pages,  with  70  illustrations.  Flexible 
leather,  $1.25  net. 

A.  M.  Seabrook,  M.  D., 

Woman  s  Medical  College  of  Philadelphia. 

••  It  is  a  most  admirable  little  book,  covering  in  a  concise  but  attractive  way  the  subject 
from  the  nurse's  standpoint." 


